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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201037
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:55:51 AM

Document Has Been Signed on 11/07/2024 11:55 AM - 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/
DIRECTOR:		ALOOT, DONNIEFACILITY TYPE:
740
ADDRESS:1408 OAKMONT PLTELEPHONE:
(925) 858-1870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 6CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Ann Jennifer Coching, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
NARRATIVE
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On 11/7/2024 at 10:05am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Ann Jennifer Coching, Caregiver. Administrator, Donnie Aloot, arrived at 10:58am.

LPA arrived to confirmed if facility has a working land-line phone. S2 was able to give LPA new facility number. Facility had failed fire inspection conducted on 10/29/2024, for not having a permit for alterations and for non-ambulatory residents.

*An immediate $500.00 civil penalty will be assessed on today's date for fire clearance*

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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 of the appeal rights, LIC421M, and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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 2
Document Has Been Signed on 11/07/2024 11:55 AM - It Cannot Be Edited


Created By: Laura Hall On 11/07/2024 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2024
Section Cited
CCR
87202(a)(1)

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(a) All facilities shall maintain a fire clearance approved by the city, county... fire department.. Prior to accepting... any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... (1) Nonambulatory persons. This requirement was not met as evidency by:
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Administrator agreed to implement a plan on what do to with non-ambulatory residents unitl fire clearance approved and submit to CCLD by POC date.
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Based on observation and record review the Licensee did not comply with the section above in have an approved fire clearance for non ambulatory, which poses an immediate health and safety check for persons in care.
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Type B
12/02/2024
Section Cited
CCR87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by:
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Administrator agreed to obtain permit from the city for alterations 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 have a permit for alterations, 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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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