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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201089
Report Date: 07/20/2021
Date Signed: 07/20/2021 06:03:49 PM

Document Has Been Signed on 07/20/2021 06:03 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GREEN FEATHERS ASSISTED LIVINGFACILITY NUMBER:
079201089
ADMINISTRATOR:PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:528 COCONUT PLTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 4DATE:
07/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kavita PramodTIME COMPLETED:
06:20 PM
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On 7/20/2021 at 10:00AM, Licensing Program Analysts (LPA) L. Ibo arrived unannounced to conduct a case management inspection due to a change of ownership. LPA met with caregiver S3, Administrator for Green Feathers arrived 30 minutes later, LPA called the Administrator Merdith Castro, per Administrator she won’t be able to meet with LPA and she gave permission to LPA to give report to Kavitha Pramod.

Facility has an approved fire clearance for 6 non ambulatory residents. Last fire inspection was conducted on 06/11/2021. LPA inspected the facility including but not limited to 4 resident rooms common areas, kitchen, dining and outside areas. Hot water measured at 108.2 degrees Fahrenheit. There was sufficient supply of perishable and non-perishable foods. First aid kit was complete.


LPAs observed the following during inspection:

At 10:08 AM , LPA observed dishwasher was rusty and stained.

At 10:09 AM, LPA observed that kitchen ventilation was oily, with yellow stained and dusty.

At 10:10 AM, LPA observed Oven was oily, glass was stained with oils and dirty.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREEN FEATHERS ASSISTED LIVING
FACILITY NUMBER: 079201089
VISIT DATE: 07/20/2021
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At 10:10 AM, LPA observed S3 was not fingerprint cleared and associated the facility. LPA verified guardian system. S3 started training/working at the facility since February 2021, records review stated that staff has been working at the facility since 2/18/2021.

At 10:12 AM , LPA observed that bedroom #3’s bathroom cabinet was broken, the cabinet door was leaning on the side.

At 10:13 AM, LPA observed, Bathroom #2 faucet was stained and dirty.

At 10:15 AM, LPA observed the carpet on hallway closet was dirty with small black particles on it.

At 10:16 AM , LPA observed that empty bedroom # 4 door was obstructed with cabinet, LPA interview S3 about the cabinet by the door, per S3, staff used that one to obstruct the door so that resident’s with Dementia won’t go out from that exit door. LPA also opened that exit door and the door alarm was not functioning.

At 10:17 AM, LPA observed that screen door was broken.

At 10:18 AM , LPA observed that side gate was locked with pod lock attached to the side gate (picture was taken)

At 11:00 AM, S4 arrived at the facility, LPA observed S4 was not associated to the facility during inspection. LPA verified on Guardian system; S4 was verified that not associated to the facility. During file review staff has been working at the facility since 2/25/2021.

At 1:16 PM, S3 TB screening was not available during file review.

At around 3:00 PM, LPA reviewed 4 resident files and 3 staff files.

Component III was waived. LPA discussed with Applicant that since she is the Administrator for two other facilities (079200843 & 079200542) she can’t be the Administrator for this facility, then Administrator verbalized that she will give up her position as Administrator for facility 079200843 to be Administrator for Green Feathers Assisted Living.

LPA is not recommending facility for license until all deficiencies are cleared. This Pre-Licensing report will be submitted to the Central Application Branch (CAB) for review. Exit interview conducted with Applicant.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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