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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201089
Report Date: 09/24/2024
Date Signed: 09/24/2024 12:26:36 PM

Document Has Been Signed on 09/24/2024 12:26 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:GREEN FEATHERS ASSISTED LIVINGFACILITY NUMBER:
079201089
ADMINISTRATOR/
DIRECTOR:		PRAMOD, KAVITHAFACILITY TYPE:
740
ADDRESS:528 COCONUT PLTELEPHONE:
(510) 331-5774
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 5DATE:
09/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Emilia PalpallatocTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 09/24/2024, at 10:40AM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Emilia Palpallatoc, Caregiver, and explained the purpose of the visit. Emilia, contacted Administrator via telephone, explained purpose of visit. Administrator gave Emilia Palpallatoc authorization to sign reports.

LPA conducted an annual inspection on 09/11/2024 and cited for the following deficiencies that has not been corrected.

  • 87608(5)(A)- LPA observed facility having two (2) residents with bed rails without doctor orders.
  • 87307(d)(6)- LPA observed facility having five(5) gallons of paint and primer, window screens and patio table umbrella in the backyard.
  • Each uncorrected deficiency is $100.00 x 6 = $1200.00.

Civil Penalties in the total amount of $1200.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected.

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREEN FEATHERS ASSISTED LIVING
FACILITY NUMBER: 079201089
VISIT DATE: 09/24/2024
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Continue fro LIC809


LPA conducted an annual inspection on 09/11/2024 and cited for the following deficiency:

  • 87705(5)(A)- LPA observed annual medical assessment and appraisal needs and service for resident with dementia were not in resident's files.


LPA wasn't able to verify during POC visit if the citation was corrected. Emilia Palpallatoc , Caregiver informed LPA of not having access to the resident's files and that the Administrator has the key to the file cabinet.

Exit interview conducted. A copy of this report, LIC809D, LIC421FC, and appeal rights provided.

Continue on LIC809D

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

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2024 12:26 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 09/24/2024 at 12:08 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: GREEN FEATHERS ASSISTED LIVING
FACILITY NUMBER: 079201089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2024
Section Cited
CCR
87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Administrator agreed to have resident's files readily available to facility staff and licensing agency staff. Administrator will send a self certifying email to CCLD by POC date.

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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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