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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201037
Report Date: 05/08/2024
Date Signed: 05/08/2024 02:53:40 PM


Document Has Been Signed on 05/08/2024 02:53 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 MANORFACILITY NUMBER:
079201037
ADMINISTRATOR:ENRIQUEZ, STEPHANIE NARESFACILITY TYPE:
740
ADDRESS:1408 OAKMONT PLTELEPHONE:
(925) 858-1870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 2DATE:
05/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Herminia P. Clarito, CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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On 05/8/2024 at 12:50pm, Licensing Program Analyst (LPA), L. Hall conducted an unannounced case management inspection regarding a denied fire clearance. LPA met with Herminia P. Clarito. Administrator, Herminia Quismorio, arrived at 1:20pm, and LPA explained the reason for the visit.

Upon arrival LPA observed S2 being the only staff at the facility. LPA also observed facility has two (2) non ambulatory residents. LPA reviewed updated fire clearance dated 4/30/2024 with Administrator. S1 stated that S2 will not longer be allowed at facility until fingerprinted and associated. S2 left facility while LPA was present.

LPA observed the following deficiencies:
  • At 12:55pm, LPA observed during record review (S2) was not fingerprinted or associated.
  • At 12:55pm, LPA observed administrator allowed S2 to work with knowledge of S2 not being fingerprinted and the only staff at the facility.


*The total amount of civil penalties assessed on today's date is $3000.00 for staff not being fingerprinted and associated.*

Continued on LIC809C.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
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 4


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: 05/08/2024
NARRATIVE
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Continued from LIC809.

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

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/08/2024 02:53 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87355(f)(1)

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(f) Violation of 87355(e) shall result in an immediate assessment of civil penalties of.. ($100) per day for a maximum of... (5) days... (1)Subsequent violations within a (12) month period will result in a civil penalty of ($100) per day for a maximum of thirty (30) days. This requirement was not met as evidence by:
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Administrator stated that S2 will not longer be allowed to work at the facility. S2 left the facility during visit. Deficiency cleared during visit.
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Based on observation and record review the Licensee did not comply with the section cited above in having S2 fingerprinted and associated, which poses an immediate health and safety risk to persons in care.
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Type B
05/13/2024
Section Cited
CCR87204(b)

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(a) All facilities shall maintain a fire clearance approved by the... city and county fire department... Prior to accepting or retaining any of the following types of persons, the...(1)Non ambulatory persons.
This requirement was not met as evidence by:
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Administrator agreed to implement a plan for residents until facility can obtain an appropriate fire clearance and submit the plan to CCLD by the POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in having the appropriate fire clearance, 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/08/2024 02:53 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87405(h)(4)

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87405 Administrator - Qualifications and Duties (h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff... This requirement was not met as evidence by:
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Administrator agreed to review regulation 87405 and submit a self-certification to CCLD by POC date that regulation has been reviewed and facility will abide by regulation going forward.
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Based on observation and interview the Licensee did not comply with the section cited above in employing qualified staff, 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4