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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201037
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:44:39 PM


Document Has Been Signed on 09/25/2024 04:44 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:ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:1408 OAKMONT PLTELEPHONE:
(925) 858-1870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
09/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Marjorie Belencion, CaregiverTIME COMPLETED:
04:55 PM
NARRATIVE
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On 9/25/2024 at 2:10pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit. LPA met with Marjorie Belencion, Caregiver. Administrator, Donnie Aloot, arrived at 2:25pm and LPA explained the purpose of the visit.

LPA received an personnel report (LIC500) on 9/13/2024. Only one (1) of six (6) staff on the LIC500 were on the facility roster in guardian. LPA conducted the visit to affirm if staff on the LIC500 was employed and working at the facility. LPA observed two (2) of the staff (S2 and S3) were working during the visit.

LPA observed the following deficiencies during visit:
  • At 2:20pm, LPA observed medicine cabinet unlocked with medication inside.
  • At 2:45pm, LPA observed S2 was not associated or fingerprinted to the facility.
  • At 2:45pm, LPA observed S3, S4, S5, and S6 were not associated to the facility.
  • At 3:10pm, LPA observed R1 with half bed rails.


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 and the report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
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 3


Document Has Been Signed on 09/25/2024 04:44 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
CCR
87465(h)(2)

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87465 (h)The following requirements shall apply to medications which are centrally stored: (2) ... medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision... This requirement was not met as evidence by:
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 Caregiver immediately locked cabinet containing medication. Deficiency cleared during visit.
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Based on observation the Licensee did not comply with the section cited above in having medications in accessible to residents which poses an immediate health and safety risk to persons in care.
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Type A
09/26/2024
Section Cited
CCR87355(d)

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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 was not met as evidence by:
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Administrator agreed to get S2 fingerprinted and submit a copy of fingerprint document to CCLD by POC date.
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Based on observation and record review S2 was not fingerprinted or associated to the facility 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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/25/2024 04:44 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2024
Section Cited
CCR
87355(e)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirment was not met as evidence by:
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Administrator agreed to submit an LIC9182 and a copy of identification for S3, S4, S5, and S6 to CCLD by POC date.
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Based on observation and record review S3, S4, S5, and S6, was not associated to the facility which poses a potential health and safety risk to persons in care.
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Type B
10/02/2024
Section Cited
CCR87608(a)(3)

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87608 (a) Based on the individual's preadmission appraisal...the facility shall provide assistance... of daily living which the resident is unable to do... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained... This requirement was not met as evidence by:
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Administrator agreed to obtain a doctor's order for bed rails for R1 and submit a copy to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section cited above in having a doctor's order for bed rails for R1, 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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3