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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610477
Report Date: 01/15/2026
Date Signed: 01/15/2026 03:29:18 PM

Document Has Been Signed on 01/15/2026 03:29 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: 3DATE:
01/15/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Cirila De La Cruz, StaffTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Plan of Correction (POC) visit at the facility. LPA met with Staff #1 (S1) and Staff #2 (S2). The Administrator was contacted via telephone and stated they were unable to come to the facility but designated staff to assist with the visit and accept the report.

The purpose of the POC visit was to determine whether deficiencies cited during the Annual Inspection on January 5, 2026 were corrected.

The following deficiencies are NOT CLEARED:

1. 87303(e)(2) – Hot Water Temperature - LPA tested the hot water temperature at resident-use faucets and observed the temperature to be 119.3°F, which does not exceed the maximum allowable temperature of 120°F. Plan of Correction met.

2. 87309(a) – Locked Storage of Hazardous Items- LPA observed knives, sharps, cleaning supplies, tools, and poisonous substances stored unlocked in kitchen cabinets and the laundry room, accessible to residents in care. Plan of Correction not met.

3. 87355(e) & 87355(e)(3) – Criminal Record Clearance and Association- LPA reviewed LIS and Guardian and did not observe Staff #1 (S1) associated with the facility, nor Staff #2 (S2) fingerprint cleared and associated prior to working. Plan of Correction not met.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 10
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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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: 01/15/2026
NARRATIVE
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4. 87307(d)(6) – Obstructed Exits - LPA observed emergency exits obstructed by a stool, trash can, and laundry basket in Bedroom #3. LPA confirmed that the dog previously obstructing the emergency exit through the activity room is in the process of being removed; however, during today’s inspection, the Bedroom #3 emergency exit remained obstructed by a stool, a trash can, and a laundry basket. Emergency exits were not maintained free of obstruction as required. Plan of Correction not met.

5. Health and Safety Code §1569.618(c)(3) – CPR and First Aid Coverage - Facility did not ensure that at least one staff member with current CPR and First Aid certification was on duty and on the premises at all times. Plan of Correction not met.

6. Health and Safety Code §1569.618(a) – Administrator Presence- Administrator was not present at the facility during normal working hours, and no documentation was provided identifying a designated facility manager responsible for operation during the Administrator’s absence. Plan of Correction not met.

7. 87412(f) & 87412(g) – Personnel Records - LPA requested personnel records; however, complete records were not available for review and were not maintained at the facility. No staff training records were provided. Plan of Correction not met.

8. 87506(a) – Resident Records- LPA reviewed resident files and observed incomplete records. Resident files for R2 and R3 lacked required documentation beyond admission agreements. Plan of Correction not met.

9. 87458(c)(1)(A) – Medical Assessment / TB Documentation - Resident medical assessments, including documentation for communicable tuberculosis, were missing from resident files. Plan of Correction not met.

10. 87211(a)(1)(A), (B), & (D) – Unusual Incident Reporting- LPA reviewed records and confirmed that hospitalization of Resident #1 (R1) on 10/07/2025 and 10/22/2025–10/31/2025 were not reported to CCL within seven (7) days as required. Administrator confirmed no reports were submitted. Plan of Correction not met.

11. 87465(h)(2) – Locked Medication Storage- LPA observed centrally stored medications for residents and staff stored unlocked in kitchen cabinets, drawers, staff room, and resident bedrooms, accessible to residents in care. Plan of Correction not met.

Deficiencies issued and appeal rights explained. Exit interview conducted and copy this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:20 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2026
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
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Administrator has agreed to have S2 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff (S2) working without a proper fingerprint cleareance which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
01/16/2026
Section Cited
CCR87355(e)(3)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working,....a licensed facility: (3) Request a transfer of a criminal record....in Section 87355(c) or This requirement is not met as evidenced by:
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Administrator has agreed to have S1 associated with the facility by the POC due date. Administrator will provide an updated LIC500 to reflect the associated staff.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff members (S1) not being associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:24 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
CCR
87307(d)(6)

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(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
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The Administrator agreed to remove the obstructions from the emergency exits and submit a photo to LPA by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in having bedroom #3 emergency exit, activity room exit and main exit blocked by a trash can, a basket, and a dog which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/22/2026
Section Cited
HSC1569.618(c)(3)

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(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training...This requirement is not met as evidenced by:
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Administrator agreed to obtain a valid CPR/first aid training for S1 and S2 and submit a proof to LPA by POD due date.
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Based on observation and interview, the licensee did not comply with the section cited above in not having a valid CPR/first aid training for a the staff available at the shift which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:28 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
HSC
1569.618(a)

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(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated...... This requirement is not met as evidenced by:
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The Administrator agreed to have a knowledgeable designee for the facility during their absense to provide all neccessary documents/records and submit a proof to LPA by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in not having a proper designee at the facility who can assist with LPA to provide documents
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for residents and staff upon request which poses/posed a potential health, safety or personal rights risk to persons in care.
Type B
01/22/2026
Section Cited
CCR87412(f)

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(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.....: This requirement is not met as evidenced by:
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Administrator agreed to maintain all personnel records of all employees at the facility and provide to LPA upon request. Administrator will inform LPA by POC due date that all personnel records are available at the facility.
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Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not available to LPA for audit and review which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:32 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
CCR
87412(g)

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(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
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The administrator agreed to review all personnel files and correct missing documentation for all staff including the Administrator. The Administrator will inform LPA by POC due date of the files at the facility.
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Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/22/2026
Section Cited
CCR87506(a)

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(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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The Administrator agreed to complete and update all three (3) residents facility files/records and inform LPA by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents files/records not available for audit at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:35 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2026
Section Cited
CCR
87458(c)(1)(A)

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(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnose......for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
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The Administrator agreed to provide all (3) residents medical assessment TB test results by POC due date to LPA.
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Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents did not have any records of TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/22/2026
Section Cited
CCR87211(a)(1)A,B&D

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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 ... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by:
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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 two incident reports (hospitalizations) shall be submitted to LPA by POC date.
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Based on interviews and review of the hospital discharge records conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalizations on 10/07/25 and 10/22/25, which poses a potential health and safety risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 01:39 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2026
Section Cited
CCR
87465(h)(2)

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(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible.........This requirement is not met as evidenced by:
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The administrator agreed to provide a vendorized training to all staff including the Administrator and will provide a copy of the training log, attendance sheet, training topic and name of the instructor will be submitted to the Licensing Agency by 01/16/2026.
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Based on observation, the licensee did not comply with the section cited above in all the residents and staff medications were accessible in the kitchen drawer, staff room, and bedroom #3 (resident) which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 03:29 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/15/2026 at 02:40 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: 01/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2026
Section Cited
CCR
87309(a)

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(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 .... This requirement is not met as evidenced by:
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Administrator will provide a training to all staff on the importance of maintaining sharps, medications, toxins, inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date.
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Based on observation and interview, the licensee did not comply with the section cited above in having all cleaning supplies, laundry detergents, a scissor, and knives unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
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 The Administrator will also provide a proper locking mechanism at the facility.

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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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