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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201037
Report Date:
03/14/2024
Date Signed:
03/14/2024 07:11:48 PM
Document Has Been Signed on
03/14/2024 07:11 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:
GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER:
079201037
ADMINISTRATOR:
ENRIQUEZ, STEPHANIE NARES
FACILITY TYPE:
740
ADDRESS:
1408 OAKMONT PL
TELEPHONE:
(925) 858-1870
CITY:
PITTSBURG
STATE:
CA
ZIP CODE:
94565
CAPACITY:
6
CENSUS:
2
DATE:
03/14/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:50 PM
MET WITH:
Herminia P. Clarito, Caregiver
TIME COMPLETED:
07:25 PM
NARRATIVE
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On 3/14/2024 at 2:50PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Caregiver, Herminia Clarito. LPA spoke with Licensee/Administrator, Stephanie Enriquez via telephone, and explained the purpose of the visit. Caregiver, Reymund Tulatbot, arrive approximately 3:30pm. The Licensee/Administrator currently holds a certificate (#6056598740) that expires on 06/10/2024. The facility’s fire clearance was approved for two (2) non-ambulatory and four (4) ambulatory residents.
LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, back yard, and garage. The facility consists of five (5) bedrooms and two (2) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.
Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/14/2024. First aid kit was observed to be complete.
Continued on LIC809C.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
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
11
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:
03/14/2024
NARRATIVE
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2
3
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5
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7
8
9
10
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Continued from LIC809.
One (1) staff record was reviewed. One (1) staff had an incomplete record and was not fingerprinted. Two (2) staff files were not available for review. LPA reviewed both resident records and medication. Staff 3 (S3) left premises.
LPA requested the following documents to be submitted to CCLD by 1/21/2024.
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
LPA observed the following deficiencies:
At 3:00pm, LPA observed during record review (S3) was not fingerprinted or associated.
At 3:05pm, LPA observed flip lock on front door.
At 3:25pm, LPA observed during record review R1 did not have a hospice notification or care plan.
At 3:30pm, LPA observed during record review there wasn't any training for staff.
At 3:35pm, LPA observed during record review that S3 did not have first aid or CPR.
At 3:40pm, LPA observed during record review that Staff 1 (S1) and Staff 2 (S2) did not have personnel files available for review.
Continued on LIC809C.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
2
of
11
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:
03/14/2024
NARRATIVE
1
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3
4
5
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16
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18
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20
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32
Continued from LIC809C.
At 3:45pm, LPA observed during record review neither resident had an appraisal needs and services plan
At 3:55pm, LPA observed knives and scissors in unlocked kitchen drawer.
At 3:58pm, LPA observed an expired resident's medication in unlocked kitchen drawer.
At 4:05pm, LPA observed 2 wheelchairs, 1 piece of Sheetrock, a walker, 4 rusted chairs, and the exit/entry gate on the left side of house broken in back yard.
At 4:10pm, LPA observed 2 rooms in garage, one (1) used as an office and the other as a staff room.
At 4:20pm, LPA observed both non-ambulatory residents residing in ambulatory rooms only.
At 4:25pm, LPA observed during record review that facility did not conduct a fire drill.
At 4:50pm, LPA observed there was not a variety of food available for residents.
*
The total amount of civil penalties assessed on today's date is $500.00 for staff not being fingerprinted and associated.*
Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. A copy the appeal rights, LIC421BG, and the report provided.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a scissors and knives locked and inaccessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
1
2
3
4
Caregiver immediately locked scissors and knives in kitchen drawer. Deficiency cleared during visit.
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S3 fingerprinted and associated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
1
2
3
4
Licensee agreed to have S3 fingerprinted and submit copy of fingerprint document to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a fire clearance for the 2 rooms in the garage which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to submit updated facility sketch and a LIC200 to CCLD by POC date.
Type B
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having non-ambulatory resident in appropriate room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to move residents to appropriate room or submit updated facility sketch and LIC200 to change ambulatory rooms to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having outdoor passage ways clear which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to remove all items and submit a photo of area to CCLD by POC date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(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 for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having personnel files available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to complete personnel files and submit self-certification that personnel files are complete and will be available for review to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having training for staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to have staff trained and submit certifications to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
7
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having one staff per shift with first aid and CPR certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to obtain first-aid certification and CPR for at least 1 staff per shift certified and submit certification to CCLD by POC date
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having an appraisal needs and services plan for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to complete an appraisal needs and services plan for each resident and submit a copy to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
8
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a quarterly fire drill conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to conduct a fire drill and submit a copy of sign-in sheet to CCLD by POC date.
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in having a hospice care plan available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
licensee agreed to obtain a copy of the hospice care plan for R1 and submit a copy to CCLD by POC date.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
9
of
11
Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(6)
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a flip lock on front door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
1
2
3
4
Licensee agreed to remove lock and submit a photo to CCLD by POC date.
Type A
Section Cited
CCR
87465(h)(2)
(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 for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having medication inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/15/2024
Plan of Correction
1
2
3
4
Caregiver immediately locked medicine in medicine closet. Deficiency cleared during visit.
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
10
of
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Document Has Been Signed on
03/14/2024 07:11 PM
- It Cannot Be Edited
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(5)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a variety of foods available for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/21/2024
Plan of Correction
1
2
3
4
Licensee agreed to obtain a variety of foods and submit photo and receipts to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Laura Hall
TELEPHONE:
(510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE:
03/14/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/14/2024
LIC809
(FAS) - (06/04)
Page:
11
of
11