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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601335
Report Date: 05/20/2024
Date Signed: 05/20/2024 04:35:22 PM


Document Has Been Signed on 05/20/2024 04:35 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:GREENLEAF CARE HOMEFACILITY NUMBER:
075601335
ADMINISTRATOR:BANGI, ANGELINE SFACILITY TYPE:
740
ADDRESS:783 GREENLEAF DRIVETELEPHONE:
(925) 240-9091
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 4DATE:
05/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:RejyJonnah Requiez, CaregiverTIME COMPLETED:
04:45 PM
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On 05/20/2024 at 3:55PM, Licensing Program Analyst (LPA) T.Syess-Gibson conducted a Health & Safety inspection as a result of client relocating. LPA met with caregiver, RejyJonnah Requiez and explained purpose of visit. Caregiver RejyJonnah contacted Administrator via telephone. Administrator, Liezyl Ajos arrived at 4:15PM, LPA explained the purpose of the visit.

Upon arrival, LPA observed total of two (2)staff(S1, and S2)and four (4) clients(C1, C2, C3 and C4) home during visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area and kitchen. Hot water temperature was measured at 108.1 degrees Fahrenheit in the common bathroom. Facility is maintained at a comfortable temperature of 80 degrees Fahrenheit for the clients in care. 7-days of non-perishable and 2-days of perishable food supplies were observed. Clients in care appear to be safe and there are no imminent health/safety concerns. Facility is noted to be clean and in good repair.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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