342700449-5-21-2026-27-AS-AMAZ-DUAPKP-20260521112328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700449
Report Date: 05/21/2026
Date Signed: 05/21/2026 11:23:36 AM

Document Has Been Signed on 05/21/2026 11:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	GREENHAVEN BLISSFUL HOME		FACILITY NUMBER:	342700449
ADMINISTRATOR/ DIRECTOR:	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:	05/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Jeanne Bayan		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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On May 21, 2026, at 9:25 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Jeanne Bayan and explained the purpose of today's visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

The administrator holds current certificate. The facility is licensed for six non-ambulatory residents, which one can be bedridden. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for two.

The LPA Martinez toured the facility with Jeanne Bayan on May 21, 2026, at 11:00 AM.

The facility has an infection control plan and was last updated on February 25, 2026. The facility has a natural disaster plan, and was last updated on February 25, 2026. The last conducted emergency drill was on March 19, 2026. LPA Martinez reviewed five staff and five resident files. The files were maintained and complete. LPA Martinez reviewed two medication administration records (MAR), and the MARs were kept current. The facility temperature measured at 71 degrees, and the facility water temperature measured at 107 degrees. The facility has an adequate food supply. The facility common areas and bedrooms are furnished and in good repair. The exterior of the home clear of debris, and emergency exit gate is in good repair.

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NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN BLISSFUL HOME	FACILITY NUMBER: 342700449
	VISIT DATE: 05/21/2026

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The facility has a first aid kit and medications are stored in a locked cabinet. The cleaning supplies and toxins are stored in a locked closet. The facility has an adequate linen supply.

The following documents were requested:
□ Annual Payment Record
□ Surety Bond
□ Current Liability Insurance
□ LIC 308 Designation of Administrative Responsibility
□ LIC 500 Current Personnel Report
□ Copy of Administrator Certificate

Please email LPA Martinez the requested documents by June 05, 2026, by 5:00 PM.

Based on this annual inspection, there were no citations given to the facility. An exit interview was given, and a copy of the report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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