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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600828
Report Date: 06/23/2022
Date Signed: 06/23/2022 12:51:32 PM


Document Has Been Signed on 06/23/2022 12:51 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:GREENRIDGE SENIOR CAREFACILITY NUMBER:
075600828
ADMINISTRATOR:LINDA JOSEPHFACILITY TYPE:
740
ADDRESS:2150 PYRAMID DRIVETELEPHONE:
(510) 758-9691
CITY:RICHMONDSTATE: CAZIP CODE:
94803
CAPACITY:38CENSUS: DATE:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Registered Nurse, Christine Dsouza.
TIME COMPLETED:
12:50 PM
NARRATIVE
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On 06/23/2022 at 11:00 AM Licensing Program Analyst (LPA) L. Holmes attempted to conduct an unannounced Change of Ownership inspection. At 10:56 AM, LPA explained the purpose of the visit to Registered Nurse (RN), Christine Dsouza. LPA reviewed Guardian, and contacted CCLD. LPA confirmed that the RN is not associated or have not obtained criminal record clearance for the facility. RN stated that she has completed background clearance for the skilled nursing unit. LPA could not obtain documents to support criminal record clearance for the Assisted Living unit.

Based on records and interviews on 06/23/2022 at 11:10 AM, LPA and CCLD office was not able to locate any association in Guardian or locate any criminal record clearance by the RN's name(s), date of birth or social security number. RN stated that he/she started working at the facility around April 2022. This citation was corrected today and RN left the facility.

The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by may result in additional Civil Penalties.

Exit interview conducted, Appeal Rights and a copy of this report provided to Registered Nurse, Christine Dsouza.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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Document Has Been Signed on 07/14/2022 01:36 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/24/2022 10:35 AM

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: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited

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87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
-This requirement is not met as evidenced by:
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-Based on observation, interviews and review of records, the licensee did not comply with the above Regulation by not associating and obtaining Criminal Record Clearance for the RN which poses a potential 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha HolmesTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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