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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610477
Report Date: 01/16/2025
Date Signed: 01/16/2025 05:00:09 PM

Document Has Been Signed on 01/16/2025 05:00 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GREEN LIFE CARE FACILITY INCFACILITY NUMBER:
197610477
ADMINISTRATOR/
DIRECTOR:		BEIKJANI, KATRINFACILITY TYPE:
740
ADDRESS:18627 ARMINTA STREETTELEPHONE:
(818) 279-4506
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Betty Griego, StaffTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At 12:10 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Betty Griego, the staff LPA and explained the reason for the visit. LPA was informed that the Administrator cannot come to the facility due to a full-time job. Physical tour was conducted with the staff and LPA observed the following:

Upon arrival LPA was informed that the census is zero (0); however, the facility did have a resident from end of March 2024 to June 1st, 2024. LPA was informed that R1 had difficulty breathing on or before 06/01/2024, and R1 passed away. However, no death report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Fire Extinguisher was last purchased on 09/12/23, and was full. The medication will be kept in a locked cabinet in the kitchen.

BEDROOMS: There are four (4) bedrooms designated for residents use. All bedrooms have sufficient closet space and have sufficient lighting. All bedrooms were observed to be properly furnished with appropriate beddings and linens. Facility has a live-in staff at the facility. The designated bedroom for the staff is bedroom (1); however, the staff is currently using bedroom #4.


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477
VISIT DATE: 01/16/2025
NARRATIVE
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Administrative: LPA was informed that the facility does not have a Certificate of Liability Insurance, LPA was not provided LIC 500.

During today's inspection, the facility is not in compliance with Title 22 regulations.

Deficiencies will be cited for today's visit. Appeal rights explained

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/16/2025 05:00 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/16/2025 at 03:07 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)A,B&D
Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's death on or before 06/01/24, which poses a potential health and safety risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's death report shall be submitted to LPA by POC date.
Type B
Section Cited
HSC
1569.605
Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477
VISIT DATE: 01/16/2025
NARRATIVE
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BATHROOMS: There are total of three (3) bathrooms and LPA observed all bathrooms to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 119°.3. The facility is using one of the bathrooms attached with bedroom #1 for staff and visitors only.

COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.

LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. There is no swimming pool or bodies of water in the facility. The facility has a back-house and the owner of the house lives in it. No residents wre observed in the back house.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational.

Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the front of the house adjacent to living and dinning rooms.

Records: Upon request of the records for staff, LPA was not provided with any records. Moreover, LPA was informed the S1 have been working at this facility since 04/20/2024. However, LPA reviewed LIS and did not observe S1 being associated with the facility. The facility had a resident from March 2024 to June 1st, 2024. LPA requested for the former resident file and LPA was not provided with one.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 01/16/2025 05:00 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/16/2025 at 03:15 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the Licensee did not provide personnel records/files of the Administrator and one staff to the LPA for review which poses a potential health and safety risk to residents in care.

POC Due Date: 01/23/2025
Plan of Correction
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Administrator to submit to the Department a complete personnel file of every staff member employed at the facility by due date to LPA.
Administrator to submit a signed certification to the Department by the due date that completed personnel files shall be accessible and remain in the facility at all times.

Type B
Section Cited
CCR
87506(d)
87506 Resident Records - (d) All resident 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 oninterview, the licensee did not comply with the section cited above by not providing R1's records/file to the LPA for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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The Licensee will submit R1's file to the LPA by the due date and write a statement of understanding about the section cited.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 01/16/2025 05:00 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/16/2025 at 03:45 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of the Community Care LIcensing Department, the licensee did not comply with the section cited above. S1's first day of work was on 04/20/2024 and as of 01/16/2025 S1 is not associated to the facility which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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Administrator has agreed to have S1 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.
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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Huma Rahimi
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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