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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201328
Report Date: 09/05/2024
Date Signed: 09/05/2024 11:32:58 AM


Document Has Been Signed on 09/05/2024 11:32 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 RESIDENTIAL CARE HOMESFACILITY NUMBER:
079201328
ADMINISTRATOR:BOND, RICHARDFACILITY TYPE:
740
ADDRESS:3033 BIRMINGHAM DRIVETELEPHONE:
(510) 847-0271
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY:6CENSUS: 0DATE:
09/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Richard Bond AdministratorTIME COMPLETED:
10:24 AM
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On 09/05/2024 at 10:00am, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge conducted an announced pre-licensing inspection LPAs met with Richard Bond, Administrator. The facility has a fire clearance for six (6) non-ambulatory residents.

LPAs inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, back yard. The facility has a total of 3 buildings an ADU with one (1) bedroom, one (1) bathroom. The main building has three (3) bedrooms and two (2) bathrooms. No bodies of water observed. There is sufficient lighting around the facility. Client’s rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms shower/tub was equipped with a nonskid mat. Passageways and hallways are free of obstruction. Locked closet available to store medications, toxins and sharps. Hot water temperature is measured at 120 Fahrenheit in shared clients' bathroom and 115 degrees Fahrenheit in the ADU unit. Fire extinguisher was purchased on 9/23/2023. First Aid kit was complete. Carbon monoxide and smoke detectors present and in working condition.

No Issues were noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.



Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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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