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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610477
Report Date: 01/05/2026
Date Signed: 01/05/2026 03:18:16 PM

Document Has Been Signed on 01/05/2026 03:18 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GREEN LIFE CARE FACILITY INCFACILITY NUMBER:
197610477
ADMINISTRATOR/
DIRECTOR:		BEIKJANI, KATRINFACILITY TYPE:
740
ADDRESS:18627 ARMINTA STREETTELEPHONE:
(818) 279-4506
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 3DATE:
01/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Cirila De La Cruz, StaffTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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At 9:45 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff #1 (S1) Cirila De La Cruz and staff #2 (S2) Emmanuel Lima and the Administrator Florence Perigrino was contacted via a telephone. LPA explained the reason for the visit. The Administrator informed LPA that they are unable to come to the facility; however, designated the staff to conducted today's visit. The physical tour was conducted with the staff and LPA observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps were observed to be unlocked in a kitchen cabinet and accessible to residents. LPA was informed that all sharps are kept unlocked all the times and the staff was never told to keep the knives locked. LPA also observed cleaning supplies, a screw driver, and a hammer unlocked in the kitchen cabinet and accessible to residents in care. A Fire Extinguisher was last purchased hanging on the wall in the by between the kitchen and laundry area. It was purchased on 10/04/2025.

Medication: The medications for staff and residents were observed in the kitchen drawer and cabinet and LPA observed that staff and residents medications are unlocked and accessible to residents in care. The staff informed LPA that the medications always remain unlocked. LPA observed medications in the staff room and the staff room was observed unlocked and accessible to residents in care. More medications were observed unlocked in bedroom #3. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477
VISIT DATE: 01/05/2026
NARRATIVE
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BEDROOMS: There are four (4) bedrooms designated for residents use. All bedrooms have sufficient closet space and have sufficient lighting. All bedrooms were observed to be properly furnished with appropriate beddings and linens. Facility has a live-in staff at the facility. The designated bedroom for the staff is bedroom (1); however, the staff is currently using bedroom #4. LPA observed room #4 unlocked and accessible to residents in care with their prescribed medication unlocked. In bedroom #3 LPA observed a scissor and resident's medication accessible and unlocked to residents in care. LPA also observed the emergency exit being blocked by a trash can and a basket.

BATHROOMS: There are total of three (3) bathrooms and LPA observed all bathrooms to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 125.4°. The facility is using one of the bathrooms attached with bedroom #1 for staff and visitors only.

COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 70°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.

LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock; however, it was observed unlocked with all laundry detergents unlocked and accessible to residents in care. The washer/dryer appear to be in good condition.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents. There is no swimming pool or bodies of water in the facility. One of the main exits in the activity room of the facility which leads to the main emergency exit of the facility was observed locked and inaccessible due to a dog. The Administrator informed LPA via a telephone that none of the staff or residents are allowed to use that exit. The exit was obstructed and blocked by a dog.

Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:47 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in not maintaining the appropriate water tempreture from 105 to 120 F degress which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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The Administrator agreed to keep water tempreture log for a week which must be from 105 to 120 F degrees and submit the log to LPA by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having all cleaning supplies, laundry detergents, a scissor, and knives unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator will provide a training to all staff on the importance of maintaining sharps, medications, toxins, inaccessible to residents in care. The administrator shall submit staff sign in sheet with the topic and the training material to LPA by POC date. The Administrator will also provide a proper locking mechanism at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:47 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff (S2) working without a proper fingerprint cleareance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator has agreed to have S2 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff members (S1) not being associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator has agreed to have S1 associated with the facility by the POC due date. Administrator will provide an updated LIC500 to reflect the associated staff.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:47 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(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
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Based on observation, the licensee did not comply with the section cited above in having a half bedrail for a resident without a Physician order on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator agreed to remove half size bed rails. POC cleared during the visit by staff removing the half bed rails. Administrator agreed to review the section and e-mail LPA verifying it.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:47 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(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 and interview, the licensee did not comply with the section cited above in having bedroom #3 emergency exit, activity room exit and main exit blocked by a trash can, a basket, and a dog which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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The Administrator agreed to remove the obstructions from the emergency exits and submit a photo to LPA by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not having a valid CPR/first aid training for a the staff available at the shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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Administrator agreed to obtain a valid CPR/first aid training for S1 and S2 and submit a proof to LPA by POD due 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:48 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in not having a proper designee at the facility who can assist with LPA to provide documents for residents and staff upon request which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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2
3
4
The Administrator agreed to have a knowledgeable designee for the facility during their absense to provide all neccessary documents/records and submit a proof to LPA by POC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not available to LPA for audit and review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
1
2
3
4
Administrator agreed to maintain all personnel records of all employees at the facility and provide to LPA upon request. Administrator will inform LPA by POC due date that all personnel records are available at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:48 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2) staff files not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
1
2
3
4
The administrator agreed to review all personnel files and correct missing documentation for all staff including the Administrator. The Administrator will inform LPA by POC due date of the files at the facility.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents files/records not available for audit at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
1
2
3
4
The Administrator agreed to complete and update all three (3) residents facility files/records and inform LPA by POC due 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 12:48 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in three (3) out of three (3) residents did not have any records of TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
1
2
3
4
The Administrator agreed to provide all (3) residents medical assessment TB test results by POC due date to LPA.
Type B
Section Cited
CCR
87211(a)(1)A,B&D
Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and review of the hospital discharge records conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalizations on 10/07/25 and 10/22/25, which poses a potential health and safety risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's two incident reports (hospitalizations) shall be submitted to LPA 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


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Document Has Been Signed on 01/05/2026 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 01/05/2026 at 01:04 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in all the residents and staff medications were accessible in the kitchen drawer, staff room, and bedroom #3 (resident) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2026
Plan of Correction
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The administrator agreed to provide a vendorized training to all staff including the Administrator and will provide a copy of the training log, attendance sheet, training topic and name of the instructor will be submitted to the Licensing Agency by 01/07/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GREEN LIFE CARE FACILITY INC
FACILITY NUMBER: 197610477
VISIT DATE: 01/05/2026
NARRATIVE
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SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational.

Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the back of the house adjacent to living and dinning rooms.

Records: Upon request of the staff and residents records/facility files, LPA was only provided with partial records for Resident #1 (R1) and LPA reviewed two other residents files and observed only the admission agreement and ID information for R2 and for R3 only an admission agreement on file. Moreover, LPA was informed the S1 have been working at this facility since 10/22/2025 and S2 is working since December of 2025. However, LPA reviewed LIS and Guardian and did not observe S1 being associated and S2 being finger print cleared and associated with the facility. LPA also did not observe any staff training records and LPA was informed that no staff training are conducted. Additionally, LPA observed that Resident #1 (R1) was taken to the hospital on 10/07/2025 and again on 10/22/2025 through 10/31/2025 for urinary tract infection; however, no incident reports were submitted to Community Care Licensing Division (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Administrative: LPA collected liability insurance certificate.

During today's inspection, the facility is not in compliance with Title 22 regulations.

Deficiencies will be cited for today's visit. Appeal rights explained

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC809 (FAS) - (06/04)
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