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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601335
Report Date: 06/11/2025
Date Signed: 06/11/2025 12:14:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/28/2025 and conducted by Evaluator Tonica Syess-Gibson
COMPLAINT CONTROL NUMBER: 15-AS-20250328151521
FACILITY NAME:GREENLEAF CARE HOMEFACILITY NUMBER:
075601335
ADMINISTRATOR:BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:783 GREENLEAF DRIVETELEPHONE:
(925) 240-9091
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 6DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Katherine Buenaflor, CaregiverTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility staff did not assist resident in obtaining transportation services
INVESTIGATION FINDINGS:
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On 06/11/2025 at 9:50AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Katherine Buenaflor, Caregiver and explained to her the reason for the visit. Katherine contacted Administrator, Liezyl Ajos via telephone. Administrator, Liezyl Ajos arrived at 10:13AM, LPA explained purpose of visit.

During the course of investigation, LPA conducted interviews with staff (S1) and (S2), resident’s physician’s report, admissions agreement, transportation and appointment logs were obtained and reviewed.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20250328151521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/11/2025
NARRATIVE
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Continued from LIC9099


Facility staff did not assist resident in obtaining transportation services

During investigation, LPA interviewed staff and reviewed documents. During interview it was revealed S1 and S2 admitted to scheduling the transportation pickup for wrong date and time resulting in R1 missing doctor appointment. R1 had a scheduled doctor appointment for 03/27/2025, scheduled transportation pickup for the 03/26/2025. During documentation review it was revealed that the scheduled pickup date for 03/28/2025 was also missed due to transportation not arriving at the facility to take R1 to rescheduled doctor appointment, R1 missed two scheduled doctor appointments.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (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. Appeal Rights and a copy of this report provided

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

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250328151521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services...

This requirement was not met as evidence by:

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Licensee agreed to implement a plan to prevent this from happening in the future and send CCL an email of plan by POC date.
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Based on records review and interviews, licensee failed to ensure that resident had transportation to attend scheduled doctor appointment, which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3