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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201089
Report Date: 09/14/2021
Date Signed: 09/14/2021 12:40:25 PM

Document Has Been Signed on 09/14/2021 12:40 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: 6DATE:
09/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Kavitha PramodTIME COMPLETED:
11:40 AM
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On 9/14/2021 at 9:35 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct continuation pre-licensing inspection due to a change of ownership. LPA met with caregiver S2, Administrator for Green Feathers arrived 30 minutes later, LPA informed 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 110.5 degrees Fahrenheit. There was sufficient supply of perishable and non-perishable foods. First aid kit was complete. 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.

....Continue to LIC809C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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: 09/14/2021
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LPA observed the following:

10:00 AM LPA conducted records review S2 is not associated at the facility. LPA verified through guardian system, S2 stated training/working since June 2021. Applicant Kavitha Pramod corrected the citation and associated S2.

10:20 AM LPA observed locked side door on room #2. Applicant admitted that facility is using the pin to lock room #2 so that resident won’t go out on that door. Applicant took out the lock from the door and educated the staffs not to put the lock on the door/doors.

LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.



Exit interview conducted with Applicant Kavitha Pramod and a copy of report was given.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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