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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201152
Report Date: 08/14/2025
Date Signed: 08/14/2025 11:48:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/27/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250327095632
FACILITY NAME:GREENRIDGE SENIOR LIVINGFACILITY NUMBER:
079201152
ADMINISTRATOR:SINGH, RUBYFACILITY TYPE:
740
ADDRESS:2150 PYRAMID DRIVETELEPHONE:
(510) 758-9600
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:38CENSUS: 21DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tamika Hill, ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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7
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9
Staff did not comply with reporting requirements.
Licensee did not ensure medications were administered by an appropriately skilled professional.
Staff did not maintain accurate records for residents.
INVESTIGATION FINDINGS:
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5
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7
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13
On 08/14/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the complaint findings for the investigation. LPA met with Tamika Hill, Manager and explained the purpose for the visit; Patrick Blanc, Administrator, was in a meeting and not available during the visit.

LPA toured the facility, requested and reviewed the following, but not limited to staff roster with scheduled hours & contact information (LIC 500), staff training records, resident roster, resident records including but not limited to Residents' (R1, R2, R3, R4, R5, R6, R7): LIC602, ID/Emergency Contact information, Progress/Hospice/Home Health Notes (March - April 2025), Centrally Stored Medications/Destruction Records, Medication Administration Records, and Physician's Orders, Death Report for R7. LPA conducted resident, and staff interviews. Administrator Personnel records and remaining documents to be provided to CCLD by 04/09/25.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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 6
Control Number 15-AS-20250327095632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREENRIDGE SENIOR LIVING
FACILITY NUMBER: 079201152
VISIT DATE: 08/14/2025
NARRATIVE
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...continued from LIC9099

Allegations: SUBSTANTIATED

Staff did not comply with reporting requirements.

On 04/02/25 and 08/06/25, LPA requested the Death Report for R7 from S1 and S2. S2 is new to the position and stated he/she would have to research the details. On 03/27/25, LPA advised S1, S2 and S3 of Title 22 reporting requirements. On 08/06/27, S2 confirmed that additional Hospice and Death Reports had not been reported for R3, R4, R5 and R7.

Staff did not maintain accurate records for residents.

On 04/02/25 and 08/06/25, LPA requested the Death Report for R7 from S1 and S2. S2 is new to the position and stated he/she would have to research the details. The additional Hospice and Death Reports for R3, R4, R5 and R7 were not available or in the files. On 08/06/25, LPA provided S2 with the Unusual Incident Report (LC624) and Death Report (LIC624A) forms to assist with maintaining accurate records for residents’ incidents, hospice, and deaths. On 08/08/25 LPA received R4’s LIC602 that was incorrect with the sex of the resident and not signed by a physician.

Licensee did not ensure medications were administered by an appropriately skilled professional.

On 04/02/25, 04/21/25, 08/06/25 and 08/07/25, LPA requested the LIC602 and staff training records for those that assisted R1 to confirm and determine R1’s primary condition and medication management requirements. Records dated 04/22/25 revealed that R1’s medication order list for an Insulin Pen-Injector was ordered 02/05/25 and administered by four different staff members throughout April. S2 stated that S3, who’s a registered nurse, normally administers insulin. Due to lack of information (LIC 602 and training records) from S1, LPA was unable to confirm that any of the staff were professionally trained to administer injections.

Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and a copy of this report provided to Tamika Hill, Manager.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/27/2025 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250327095632

FACILITY NAME:GREENRIDGE SENIOR LIVINGFACILITY NUMBER:
079201152
ADMINISTRATOR:SINGH, RUBYFACILITY TYPE:
740
ADDRESS:2150 PYRAMID DRIVETELEPHONE:
(510) 758-9600
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:38CENSUS: 21DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tamika Hill, ManagerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not provide planned activities for residents.
Staff spoke to residents in an inappropriate manner.
Licensee retained resident(s) requiring a higher level of care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
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12
13
On 08/14/25 around 09:00 AM L. Holmes, Licensing Program Analyst (LPA), arrived unannounced to deliver the complaint findings for the investigation. LPA met with Tamika Hill, Manager and explained the purpose for the visit; Patrick Blanc, Administrator, was in a meeting and not available during the visit.

LPA toured the facility, requested and reviewed the following, but not limited to staff roster with scheduled hours & contact information (LIC 500), staff training records, resident roster, resident records including but not limited to Residents' (R1, R2, R3, R4, R5, R6, R7): LIC602, ID/Emergency Contact information, Progress/Hospice/Home Health Notes (March - April 2025), Centrally Stored Medications/Destruction Records, Medication Administration Records, and Physician's Orders, Death Report for R7. LPA conducted resident, and staff interviews. Administrator Personnel records and remaining documents to be provided to CCLD by 04/09/25.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20250327095632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREENRIDGE SENIOR LIVING
FACILITY NUMBER: 079201152
VISIT DATE: 08/14/2025
NARRATIVE
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...continued from LIC9099

UNSUBSTANTIATED

Licensee did not provide planned activities for residents.

On 04/02/25, LPA arrived unannounced and upon arrival LPA observed three (3) – four (4) residents engaged in morning exercises and during departure the residents were present for Music and Memory activities. S2 provided LPA with an activities calendar for April with 1-5 various activities each day of the month. In addition to being the facility’s Manager, S2 was also an activities director and still oversees what is scheduled on the monthly calendar.

Staff spoke to residents in an inappropriate manner.

R4 was in his/her room and did not respond when asked about the treatment at the facility and if he/she felt everything was okay. R7 is deceased. R5 and R6 have some physical limitations, both have home health aide assistance, are neither stated that the were spoken to inappropriately or heard staff speak to other residents in an inappropriate manner. LPA confirmed that Home Health Aides who are mandated reporters (W1, W2 & W3) never heard or witnessed staff speaking to residents in an inappropriate manner.

Licensee retained resident(s) requiring a higher level of care.

LPA reviewed Resident (R1, R2, R3, R4, R5, R6) records. On 03/26/25 and 03/28/25, R2’s care notes recorded a swallow assessment and dysphasia management. On 03/12/25, R4’s progress notes states there was wound care (not staged), good and no concerns; on 03/14/25 R4 denied pain and discomfort. On 04/14/25 Hydrofera Blue dressings applied to R6’s leg wound (not staged), and on 04/11/25 the wound was healing without infections. The records reviewed did not reveal that R1, R2, R3, R4, R5, and R6 required a higher level of care.

Based on LPA’s interviews, observations, and records reviewed, the allegations are UNSUBSTANTIATED. The finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met.

Exit interview conducted, and a copy of this report provided to Tamika Hill, Manager.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20250327095632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENRIDGE SENIOR LIVING
FACILITY NUMBER: 079201152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2025
Section Cited
HSC
87211(a)
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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...resident's name, age,...
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Licensee/ADM to review regulations by POC, provide in-service training for care staff and ensure that all required written reports are provided to CCLD.
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sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. -This requirement is not met as evidenced by:
Licensee/ADM did not provide the required written reports for residents to CCLD.
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Type B
08/21/2025
Section Cited
HSC
87629(b)(1)
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87629 Injections (b) In addition to Section 87611, General Requirements for Allowable Health Conditions... residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional
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Licensee/ADM to review regulations, provide in-service training, and update staff’s training records by POC.
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should the resident require assistance.-This requirement is not met as evidenced by:

Licensee/ADM did not ensure that injections were administered by an appropriately skilled professionals.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20250327095632
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREENRIDGE SENIOR LIVING
FACILITY NUMBER: 079201152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2025
Section Cited
HSC
87506(a)
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2
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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. -This requirement is not met as evidenced by:
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Licensee/ADM to review regulations by POC, provide in-service training for care staff and ensure that all resident records are maintained to CCLD.
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Licensee/ADM did not ensure that all resident records were maintained.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6