079201089-9-11-2024-15-AS-TSGN-D8ZSTU-20240911141008

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201089
Report Date: 09/11/2024
Date Signed: 09/11/2024 02:10:21 PM

Document Has Been Signed on 09/11/2024 02:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	GREEN FEATHERS ASSISTED LIVING		FACILITY NUMBER:	079201089
ADMINISTRATOR:	PRAMOD, KAVITHA		FACILITY TYPE:	740
ADDRESS:	528 COCONUT PL		TELEPHONE:	(510) 331-5774
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	6	CENSUS: 5	DATE:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Vilma Noda, Caregiver		TIME COMPLETED:	02:21 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 09/11/2024 at 10:27AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Vilma Noda, spoke with Administrator, Pramod Balanandan via telephone, and explained the purpose of the visit. The Administrator arrived at 11:15AM and currently holds a certificate (#6050378740) that expires on 01/16/2025. Facility has census of 5. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Caregiver, Candido Nerona including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 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 109.9 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 08/30/2024. Emergency Disaster Plan was last posted on 06/02/2024. First aid kit was observed to be complete. Fire drill was last conducted on 08/17/2024. Continued LIC809C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
	VISIT DATE: 09/11/2024

NARRATIVE

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Continued from LIC809.

LPA reviewed five (5) staff records and five (5) resident records. LPA also reviewed medications.

LPA requested updated copies of the following documents to be submitted to CCLD by 09/18/2024

· 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 10:40AM, LPA observed during tour, two (2) of the five (5) residents has bed rails without doctor's orders.
· At 10:50AM, LPA observed during tour of backyard, a five (5) gallons of paint and primer, broken window screens and an umbrella for a patio table in the backyard leaning against the fence.
· At 12:25PM, LPA observed during record review R1 doesn't have a current medical assessment (LIC602) The last medical assessment is dated 03/08/2023.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/11/2024 02:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(5)(A)

87608 Postural Supports 5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 two (2) residents with bed rails without doctor orders which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Administrator agreed to provide doctor orders or remove beds from residents room and send CCLD an email of doctors orders or photo of removal by POC date

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (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 five(5) gallons of paint and primer, window screens and patio table umbrella in the backyard which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Administrator agreed to remove items and send a photo via email 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: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 09/11/2024 02:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(5)(A)

87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having an annual medical assessment and appraisal needs and service for resident with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Administrator agreed to obtain an updated medical assessment and complete appraisal needs and service plan for all residents in care and provide CCLD a self certifying email of completion 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: Tonica Syess-Gibson	TELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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