275294305-1-23-2023-24-AS-SHUT-CND2RA-20230123163714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 275294305
Report Date: 01/23/2023
Date Signed: 01/23/2023 04:37:35 PM

Document Has Been Signed on 01/23/2023 04:37 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	GREEN PINES RESIDENTIAL CARE HOME		FACILITY NUMBER:	275294305
ADMINISTRATOR:	LUMBI, PAUL N.		FACILITY TYPE:	740
ADDRESS:	11 SAGUARO CIRCLE		TELEPHONE:	(831) 424-7336
CITY:	SALINAS	STATE: CA	ZIP CODE:	93905
CAPACITY:	6	CENSUS: 5	DATE:	01/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Licensee, Paul Lumbi		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee Paul Lumbi, Continual Administrator's Certification expires 09/15/2023. There are currently 5 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and had required furnishings. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. Smoke alarms were tested and are operational. First Aid kit is on site and complete.

LPA Hurt observed several facility windows without screens, and one window with a ripped window screen.
LPA Hurt observed the cabinets in the bathroom of the master bedroom to be coming off the hinges, and one cabinet completely missing.

LPA Hurt observed a resident bedroom on the left side of the home to have a large crack going through the entire window. LPA Hurt observed several containers inside the facility refrigerator not labeled or dated. LPA Hurt observed the door to the facility garage unlocked leaving chemicals and supplies accessible to residents.
LPA Hurt observed a small dog in the backyard with no clean water, and appeared to have mange and other health issues. LPA Hurt observed the facility fire extinguisher last serviced February of 2020.
LPA Hurt observed Amlodipine medication for Resident 1 not documented on any Centrally Stored Medication Logs.

Continued on 809C...

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

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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Document Has Been Signed on 01/23/2023 04:37 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN PINES RESIDENTIAL CARE HOME	FACILITY NUMBER: 275294305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(a)

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. The following food service requirements shall apply: 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 LPA observed several food items inside the facility refrigerator inside containers with no labels or dates, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2023
	Plan of Correction
1 2 3 4	Licensee will conduct staff training on food service requirements and submit proof to LPA by 01/30/2023

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 LPA observed two windows without screens, one window with a hole in the screen, and another window with a large crack, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of all window repairs to LPA by 01/30/2023 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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2023 04:37 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN PINES RESIDENTIAL CARE HOME	FACILITY NUMBER: 275294305
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 LPA observed the facility door leading from laundry area into garage to be unlocked leaving cleaning solutions accesssible to residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/23/2023
	Plan of Correction
1 2 3 4	Licensee will send proof of staff training on hazardous chemicals to LPA by 01/30/2023 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: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN PINES RESIDENTIAL CARE HOME	FACILITY NUMBER: 275294305
	VISIT DATE: 01/23/2023

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...Continued from 809

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee Paul Lumbi, and copy of report left at facility

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC809 (FAS) - (06/04)

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