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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700140
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:03:52 PM


Document Has Been Signed on 08/04/2023 03:03 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:RETREAT AT GREENHURST LLC, THEFACILITY NUMBER:
342700140
ADMINISTRATOR:TIN, ANTONETTEFACILITY TYPE:
740
ADDRESS:986 GREENHURST WAYTELEPHONE:
(916) 549-2724
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 4DATE:
08/04/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Natividad RebuyonTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived on a subsequent visit. LPA met with Natividad Rebuyon, Caregiver and stated the purpose of the visit. This visit is to ensure the health and safety of the residents residing in the home. Administrator Certificate expires 7/5/2024.

Upon arrival LPA observed 1 resident sitting at the table watching television while having lunch. 3 residents were sleeping during this visit. LPA observed the (RCFE) Complaint Poster (PUB 475) is not in compliance with the regulations which shall be 20" x 26" in size and posted in the main entryway of the facility.

The facility is licensed for a capacity of 6 non-ambulatory of which 1 maybe bedridden. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a hospice waiver for 4 of which there is 1 residents receiving hospice services at this time.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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 08/04/2023 03:03 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: RETREAT AT GREENHURST LLC, THE
FACILITY NUMBER: 342700140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87468(c)(2)(A)

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Personal Rights Licensees shall prominently post...the Elderly (RCFE) Complaint Poster (PUB 475)...shall be 20" x 26" in size and be posted in the main entryway of the facility.
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Administrator shall submit proof of the poster posted in the facility by POC due date.
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This requirement is not met as evidenced by: Based on LPA observation during a tour of the facility during this visit. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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