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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600828
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:41:15 PM

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:GREENRIDGE SENIOR CAREFACILITY NUMBER:
075600828
ADMINISTRATOR:LINDA JOSEPHFACILITY TYPE:
740
ADDRESS:2150 PYRAMID DRIVETELEPHONE:
(510) 758-9691
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:38CENSUS: 10DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Linda JosephTIME COMPLETED:
03:20 PM
NARRATIVE
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On 7/22/2021 at 12:55 PM, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with Administrator Linda Joseph. Census of 10.

LPA inspected the facility inside and outside. LPA observed no bodies of water. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is the Administrator. LPA observed COVID-19 posters posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan and maintains record of routine screening for residents and staff. Facility has enough supplies of PPEs, paper supplies and hygiene supplies.

Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. There was at least 7 days of nonperishable and 2 days of perishable foods. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational.

...Continued to LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 3
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: GREENRIDGE SENIOR CARE
FACILITY NUMBER: 075600828
VISIT DATE: 07/22/2021
NARRATIVE
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LPA observed:
S3 was not associated to the facility. S3 left the facility immediately.


Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed Linda Joseph.

Exit interview conducted. Appeal Rights and copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: GREENRIDGE SENIOR CARE
FACILITY NUMBER: 075600828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review the licensee did not comply with the section cited above in S3 was not associated at the facility which poses an immediate health, safety risk to persons in care.
POC Due Date: 07/22/2021
Plan of Correction
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S3 need to be associated at the facility before working. S3 left the facility immediately. Deficiency was cleared and corrected.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3