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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201037
Report Date: 02/05/2021
Date Signed: 02/05/2021 03:53:49 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:GREEN PASTURES RESIDENCES LLC - OAKMONT MANORFACILITY NUMBER:
079201037
ADMINISTRATOR:ENRIQUEZ, STEPHANIE NARESFACILITY TYPE:
740
ADDRESS:1408 OAKMONT PLTELEPHONE:
(925) 858-1870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 0DATE:
02/05/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Stephanie and Jose Enriquez, AdministratorsTIME COMPLETED:
02:40 PM
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On 02/05/2021 at 02:00pm, Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing tele-inspection through Facetime due to the shelter in place order directed by the Governor. LPA met with Stephanie and Jose Enriquez, Administrators. The facility has an approved fire safety clearance for six (6) residents 4 non-ambulatory and 2 ambulatory.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and backyard. The facility has a total of five (5) bedrooms and two (2) bathrooms. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars and non skid mats. Passageways and hallways are free of obstruction. Carbon monoxide and smoke detectors were in working condition.

Prior to licensure, the following shall be corrected and faxed to CCL by 02/12/2021:
  • A copy of the fire extinguisher receipt.
  • A picture of non-perishable foods.
  • A picture of locks on cabinets for sharps, toxins, and medications.
  • Signed copy of the emergency disaster plan.
  • Informational documents and posters posted (i.e personal rights and emergency disaster plan)
  • A picture of the first-aid kit

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
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 2
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 RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037
VISIT DATE: 02/05/2021
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Continued from LIC809.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted with Administrators and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
LIC809 (FAS) - (06/04)
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