342700449-5-14-2021-27-AS-VBRN-C2ZVGS-20210514162601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700449
Report Date: 05/14/2021
Date Signed: 05/14/2021 04:26:27 PM

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:	GREENHAVEN BLISSFUL HOME		FACILITY NUMBER:	342700449
ADMINISTRATOR:	TORRES, CHRISTINE		FACILITY TYPE:	740
ADDRESS:	6200 FENNWOOD CT		TELEPHONE:	(916) 753-7564
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 6	DATE:	05/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Christine Torres		TIME COMPLETED:	04:45 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	Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms:not associated with a pre-existing condition? · Fever or chills · Cough · Shortness of breath/difficulty breathing · Fatigue · Muscle or body aches · Headaches · New loss of taste or smell · Sore throat · Congestion or runny nose · Nausea or vomiting · Diarrhea Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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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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: GREENHAVEN BLISSFUL HOME	FACILITY NUMBER: 342700449
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2021 Section Cited	1 2 3 4 5 6 7	General Food Service Requirements All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed expired/undated food items. Based on LPA's observation of expired food in the refrigerator such as cheese, milk, cream, mustard, pesto, ketchup and there were other items with no expiration dates such as fish in the freezer. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 05/17/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed hazardous materials in the back yard. Based on LPA's observation of rusty tomato cage, exposed nails, broken boards,and loose bricks. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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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: GREENHAVEN BLISSFUL HOME	FACILITY NUMBER: 342700449
	VISIT DATE: 05/14/2021

NARRATIVE

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Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

Licensing Program Analyst(s) (LPA) Victoria Brown and Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/14/21 at 2:45pm. LPAs met with Reyna Ly Romero, Caregiver who contacted the Administrator regarding todays visit. LPA's was allowed entry into the facility that is licensed to serve a total capacity of 6 residents of which 5 maybe Non-ambulatory and 1 bedridden. Administrator arrived within 15 minutes to assist with todays visit. Administrator Certificate expired 10/23/2020, the classes and fees were completed. The Administrator is waiting to receive the updated certificate.

LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 78*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 106.6*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. There is 1 resident receiving hospice services at this time.
The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.
LPA observed expired foods that will be cited during this visit. LPA's observation consisted of expired food in the refrigerator such as cheese, milk, cream, mustard, pesto, ketchup and there were other items with no expiration dates such as fish in the freezer. Facility shall at all times maintain food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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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: GREENHAVEN BLISSFUL HOME	FACILITY NUMBER: 342700449
	VISIT DATE: 05/14/2021

NARRATIVE

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Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Administrative Responsibility LIC308
Liability Insurance
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Once received from the Department

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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