GREEN LIFE CARE FACILITY INC

Official classification

Type A

Official code

1569.10

Regulation authority

HSC

What the official deficiency says

1569.10 RCFE; license or permit; necessity No person, firm, partnership, association, or corporation within the state.....without a current valid license or current valid special permit... This requirement is not met as evidenced by: Based on interviews conducted, LPA was informed that R1, R2, R3, were receiving elements of care and supervision, which posed an immediate health and safety risk or personal rights risk to residents in care.

Official plan of correction

Operator will submit an application to CCL by the POC due date of 02/09/2026.

Deadline recorded: Feb 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

Administrator has agreed to have S2 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working,....a licensed facility: (3) Request a transfer of a criminal record....in Section 87355(c) or This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: 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.

Official plan of correction

The Administrator agreed to remove the obstructions from the emergency exits and submit a photo to LPA by POC due date.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(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...This requirement is not met as evidenced by: 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.

Official plan of correction

Administrator agreed to obtain a valid CPR/first aid training for S1 and S2 and submit a proof to LPA by POD due date.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(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...... This requirement is not met as evidenced by: 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

Official plan of correction

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. for residents and staff upon request which poses/posed a potential health, safety or personal rights risk to persons in care.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(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.....: This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

The Administrator agreed to complete and update all three (3) residents facility files/records and inform LPA by POC due date.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(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 diagnose......for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: 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.

Official plan of correction

The Administrator agreed to provide all (3) residents medical assessment TB test results by POC due date to LPA.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 ... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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.........This requirement is not met as evidenced by: 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.

Official plan of correction

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 01/16/2026.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 .... This requirement is not met as evidenced by: 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.

Official plan of correction

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.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction 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.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction 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.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction Administrator has agreed to have S2 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction 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.

Official classification

Type A

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/06/2026 Plan of Correction 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.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction The Administrator agreed to remove the obstructions from the emergency exits and submit a photo to LPA by POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction Administrator agreed to obtain a valid CPR/first aid training for S1 and S2 and submit a proof to LPA by POD due date.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction 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.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction 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.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction 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.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction The Administrator agreed to complete and update all three (3) residents facility files/records and inform LPA by POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction The Administrator agreed to provide all (3) residents medical assessment TB test results by POC due date to LPA.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 01/12/2026 Plan of Correction 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.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 01/07/2026 Plan of Correction 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.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

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 Based on interviews conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's death on or before 06/01/24, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction 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 death report shall be submitted to LPA by POC date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests... This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview the Licensee did not provide personnel records/files of the Administrator and one staff to the LPA for review which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction Administrator to submit to the Department a complete personnel file of every staff member employed at the facility by due date to LPA. Administrator to submit a signed certification to the Department by the due date that completed personnel files shall be accessible and remain in the facility at all times.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records - (d) All resident 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 Based oninterview, the licensee did not comply with the section cited above by not providing R1's records/file to the LPA for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction The Licensee will submit R1's file to the LPA by the due date and write a statement of understanding about the section cited.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Deficient Practice Statement Based on record review of the Community Care LIcensing Department, the licensee did not comply with the section cited above. S1's first day of work was on 04/20/2024 and as of 01/16/2025 S1 is not associated to the facility which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 01/20/2025 Plan of Correction Administrator has agreed to have S1 get fingerprinted by the POC due date. Administrator will provide an updated LIC500 to reflect new staff.