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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601335
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:52:09 PM

Document Has Been Signed on 07/19/2024 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREENLEAF CARE HOMEFACILITY NUMBER:
075601335
ADMINISTRATOR/
DIRECTOR:		BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:783 GREENLEAF DRIVETELEPHONE:
(925) 240-9091
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 3DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:13 AM
MET WITH:Maricar Michellin and Gina Manalo, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 07/19/2024 at 11:13AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived to conduct an unannounced 1-Year Required inspection. LPA was greeted by Maricar Michellin. LPA met with Caregiver Gina Manlo who spoke with Administrator, Liezyl Ajos via telephone, and explained the purpose of the visit. The Administrator arrived at 11:43AM. Administrator currently holds a certificate (#7019104740) that expires on 12/01/2025. Facility has census of 3. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA observed a Maricar Michellin preparing food and Two (2) residents eating at the kitchen table upon entry.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 85 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/11/2023. Emergency Disaster Plan was last posted on 12/25/2023. First aid kit was observed to be complete. Fire drill was last conducted on 12/11/2023.

Continued LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335
VISIT DATE: 07/19/2024
NARRATIVE
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Continued from LIC809.

Three (3) staff records were reviewed. During record review one (1) staff did not have Health Screening

LPA reviewed all Three (3) resident records, During record review all three(3) residents didn't have Appraisal Needs and Service Plans

LPA requested updated copies of the following documents to be submitted to CCLD by 07/26/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· Liability Insurance
· Current Administrator’s Certificate

LPA observed the following deficiencies:

· At 11:20AM, LPA observed house guest preparing food in the kitchen. (S1) advised LPA of house guest not being associated or fingerprinted and that she's only visiting from another country
· At 12:05PM, LPA observed unlocked closet with laundry detergent inside
· At 12:11PM, LPA observed unlocked drawer with scissors

Continue on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335
VISIT DATE: 07/19/2024
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continued from LIC809C

· At 12:12PM LPA observed Refrigerator door handle was broken
· At 1:28PM LPA observed during record review that all three (3) residents were missing Appraisal Needs and Service Plans
· At 1:56PM LPA observed during record review that (S3) did not have health screening
· At 2:05PM LPA observed roaches crawling on counter top near fruit basket

*The total amount of civil penalties assessed on today's date is $100.00 for volunteer not being associated or finger print cleared. *

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, LIC421BG, and the report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 03:52 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/19/2024 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having volunteer associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Administrator had volunteer leave immediatley. Deficiency cleared during visit
Type A
Section Cited
CCR
87411(f)
87411 Personnel Requirements – General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. .....

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, the licensee did not comply with the section cited above in not having S3 health screening which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Administrator agreed to provide an email of S3 health screening to CCLD by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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Document Has Been Signed on 07/19/2024 03:52 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/19/2024 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having scissors inside an unlocked kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Caregiver immediately locked scissors in kitchen drawer. Deficiency cleared during visit.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having laundry detergent in an unlocked closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Caregiver immediately locked closet with laundry detergent . Deficiency cleared during visit
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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Document Has Been Signed on 07/19/2024 03:52 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/19/2024 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having roaches in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator agreed to provide an email of pest control invoice with services provided by pest control company to CCLD by POC date
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in broken refrigerator handle in kitchen which poses safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Administrator agreed to repair or replace refrigerator and provide CCLD an email of photos by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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Document Has Been Signed on 07/19/2024 03:52 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 07/19/2024 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENLEAF CARE HOME
FACILITY NUMBER: 075601335

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having all residents in care Appraisal Needs and Service Plan in residents files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator agreed to complete and file Appraisal Needs and Service Plans for all residents in care and provide a self certifying email to CCLD by POC date
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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