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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700140
Report Date: 08/28/2023
Date Signed: 08/28/2023 04:01:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230825095012
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:
08/28/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Antonette TinTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegation on 8/28/23 at 9:30am. LPA met with Antonette Tin and stated the purpose of the visit. LPA conducted interviews during this visit of staff and resident #1 (R1). Regarding allegation, "Staff did not seek medical attention to resident in care." LPA conducted interviews which revealed that Administrator Antonette Tin did not seek medical attention upon the request of R1's Licensed Skilled Professional. Administrator stated that she was reiterating how a lack of medication could affect R1's behavior based on R1's past history and responsible party information. Based on interviews and the admittance from the Administrator that she did not seek medical attention for R1 because R1 was not having behaviors. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D 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.
Substantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20230825095012
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2023
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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Licensee/Administrator shall submit in writing that any medical attention upon request or any other circumstance that threatens the safety of the residents will be handled according to Title 22 regulations at all times. Please fax the POC by 8/29/23.
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This requirement is not met as evidenced by: Based on Administrator admittance confirming she did not seek medical attention as requested for R1. This poses an immediate 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
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