079201089-8-17-2022-15-AS-LIBO-CHDRNL-20220817131030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201089
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:11:47 PM

Document Has Been Signed on 08/17/2022 01:11 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
CCLD Regional Office, 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:	08/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kavitha Pramod, Administrator		TIME COMPLETED:	01:30 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 8/17/2022 at 10:30AM, Licensing Program Analyst (LPA) L. Ibo conducted an annual infection control inspection and met with S3, LPA called S1 and S2 and explained the purpose of the visit. S2 arrived at the facility after 45mins. LPA observed 5 residents during the visit. Facility has a completed mitigation plan and copy of infection control plan was requested to be submitted by 8/26/2022. LPA inspected the facility inside and outside. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Pathways were observed to be free of obstruction and fire hazards. Infection control designated leader is the Administrator. There was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 75 degrees Fahrenheit. A certified administrator is on site a minimum of 20 hours a week to oversee proper business operation. Smoke and Carbon monoxide detectors were operational. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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 08/17/2022 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

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 unlocked cabinet with poisonous cleaning products was found under the kitchen sink and LPA observed unlocked centrally store medication storage which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/17/2022
	Plan of Correction
1 2 3 4	Corrected during the visit.

Type A

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation licensee did not comply with the section cited, side gate was locked using pod lock which posed an immediate Health and Safety risk to residents in care.
	POC Due Date: 08/17/2022
	Plan of Correction
1 2 3 4	Administrator corrected deficiency during inspection. Padlock on main security exit gate was removed.

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: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2022 01:11 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(d)(5)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility do not have proof staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2022
	Plan of Correction
1 2 3 4	Administrator agreed to send copy of covid19 training for all staff 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: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GREEN FEATHERS ASSISTED LIVING	FACILITY NUMBER: 079201089
	VISIT DATE: 08/17/2022

NARRATIVE

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LPA observed the following:

· Medications supply room was accessible to residents in care. – corrected during visit
· Cleaning supplies and disinfectant are accessible to residents in care - corrected during visit
· Side gate was locked using pod lock- corrected during visit
· Auditory signals on exit doors are turned off- corrected during visit.
· Facility does not document daily temperature and COVID-19 symptom checks, and any change in condition for staff - technical assistance provided
· Licensee has not provided all staff fit testing for N95 respirators – technical assistance provided
· Facility do not have proof staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control. – type B citation.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with Kavitha Pramood.

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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