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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201328
Report Date: 07/30/2025
Date Signed: 07/30/2025 06:06:16 PM

Document Has Been Signed on 07/30/2025 06:06 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 PASTURES RESIDENTIAL CARE HOMESFACILITY NUMBER:
079201328
ADMINISTRATOR/
DIRECTOR:		BOND, RICHARDFACILITY TYPE:
740
ADDRESS:3033 BIRMINGHAM DRIVETELEPHONE:
(510) 847-0271
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 6CENSUS: 1DATE:
07/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:RICHARD BOND, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
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At approximately 12:50PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a Required 1 Year annual inspection and met with Administrator Richard Bond Administrator, and explained the reason for the visit.

LPA conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. There is a sufficient supply of hygiene products, paper products, and linens available for resident use. Medication was centrally stored and secure.

LPA reviewed 1 of 1 resident records, which were incomplete. LPA reviewed a sample of staff records. LPA reviewed 4 staff files. Staff files were incomplete. Administrator's Certificate# (6068508740) was current with an expiration date of 01/10/2026.

The facility conducted fire and evacuation drill on 7/18/2025. Facility's fire extinguishers were last inspected 09/10/2024. Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures in shared residents bathroom was within Title 22 regulations measured at 111.3 degrees Fahrenheit.

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/30/2025 06:06 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/30/2025 at 03:26 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 PASTURES RESIDENTIAL CARE HOMES
FACILITY NUMBER: 079201328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above having unlocked screw driver located in a drawer in the family/recreation room. knives in a drawer in the kitchen with only a child safety lock which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Caregiver put screwdriver in locked drawer and Administrator agreed to change the lock by the POC date and submit photo to the department.
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having vitamins in an unlocked drawer located in the family/recreation room which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Caregiver locked vitamins during visit. DEFICIENCY CLEARED DURING VISIT.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2025


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 PASTURES RESIDENTIAL CARE HOMES
FACILITY NUMBER: 079201328
VISIT DATE: 07/30/2025
NARRATIVE
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Continued from LIC809C.

DEFICIENCIES OBSERVED BY LPA
  • At 1:00pm, LPA observed staff member not associated to the facility and not fingerprint cleared.
  • At 1:05pm, LPA observed chemicals accessible lock broken.
  • At 1:10pm, LPA observed family/recreation room converted into a bedroom.
  • At 1:30pm, LPA observed a screw driver in an unlocked drawer in the family/recreation room.
  • At 1:32pm, LPA observed chewable vitamins in an unlocked drawer in the family/recreation room.
  • At 1:45pm, LPA observed two unlocked sheds located in the backyard.
  • At 1:50pm, LPA observed window cleaner, a shovel and comet unlocked in the backyard at the outside sink.
  • At 2:10pm, LPA observed plank on the fence broken, sowing machine, metal screen, broke down metal cabinet, bucket of nails, tool box with tools such as saw, jumper cables, electoral outlet. Hedge trimmers, screws, ladder, heavy duty stapler, 2 sinks, wood planks located on the side yard.

*The total amount of civil penalties assessed on today's date is $500.00 for staff not being fingerprinted and associated.*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (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. A copy the appeal rights, LIC421BG, and the report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2025 06:06 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/30/2025 at 04:29 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 PASTURES RESIDENTIAL CARE HOMES
FACILITY NUMBER: 079201328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above not having resident records at the facility which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee agreed to complete personnel files and submit self-certification that personnel files are complete and will be available for review to CCLD by POC date.
Type B
Section Cited
CCR
87355(d)(3)
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having S3 fingerprinted and associated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2025
Plan of Correction
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Licensee agreed to have S3 fingerprinted and submit copy of fingerprint document to the department by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/30/2025 06:06 PM - It Cannot Be Edited


Created By: Carol Fowler On 07/30/2025 at 04:41 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 PASTURES RESIDENTIAL CARE HOMES
FACILITY NUMBER: 079201328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85087(a)(3)
Buildings and Grounds.
"No room used as a common area shall be used as a bedroom for any person."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by creating a staff room in the family/recreation area which poses/posed a potential health and safety risk to persons in care. **Caregiver informed LPA the facility converted the family/recreation room into a staff room.**
POC Due Date: 08/06/2025
Plan of Correction
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Administrator agreed to turn the created caregivers room back into family/recreation room and submit photos to the facility by the POC date.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having plank on the fence broken, sowing machine, metal screen, broke down metal cabinet, bucket of nails, tool box with tools such as saw, jumper cables, electoral outlet. Hedge trimmers, screws, ladder, heavy duty stapler, 2 sinks, wood planks located on the side yard and 2 unlocked storage sheds. which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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Administrator agreed to fix the plank on the fence broken, remove sowing machine, metal screen, broke down metal cabinet, bucket of nails, tool box with tools such as saw, jumper cables, electoral outlet. Hedge trimmers, screws, ladder, heavy duty stapler, 2 sinks, wood planks located on the back and side yard and will purchace locks for the 2 unlocked storage sheds located in the backyard and submit photos to the Department by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2025


LIC809 (FAS) - (06/04)
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Created By: Carol Fowler On 07/30/2025 at 05:31 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 PASTURES RESIDENTIAL CARE HOMES
FACILITY NUMBER: 079201328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having a broken lock on the door which has bleach, bleach wipes, laundry soap and other chemicals accessible which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Administrator agreed to replace the lock and submit a photo to the Department by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2025


LIC809 (FAS) - (06/04)
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