342700474-8-21-2020-27-AS-VBRN-BSPRPJ-20200821131201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 08/21/2020
Date Signed: 08/21/2020 01:12:08 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 PLACE INDEPENDENT LVG AND ASSISTED LVG		FACILITY NUMBER:	342700474
ADMINISTRATOR:	JO FRANKLIN		FACILITY TYPE:	740
ADDRESS:	6350 RIVERSIDE BLVD		TELEPHONE:	(916) 427-1133
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	48	CENSUS: 82	DATE:	08/21/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Jo Franklin		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/21/2020 at 12:06pm to conduct a health and safety check on the residents. LPA met with Jo Franklin and stated the purpose of the visit. LPA and Jo Franklin toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 82 residents receiving care and supervision in addition to 31 residents who relocated to the facility due to precautionary measures.

Due to Covid 19 Precautionary measures the following was asked and observed during this visit:

Do any residents or staff have the following symptoms: fever, cough, or difficulty breathing that is not associated with a pre-existing condition? No

Did any residents or staff have any contact with a laboratory-confirmed case of COVID-19 in the past 14-days? No

Is any resident or staff being evaluated for COVID-19 by a healthcare worker in a U.S. healthcare setting? No

Has any resident or staff traveled within the last 14 days to a country considered to be at high-risk for COVID-19 by the Center for Disease Control’s travel website? No

Has any resident or staff been quarantined for COVID-19 in the past 30 days? Yes

Entry points

PPE stations and practicing throughout facility-Surveillance Screening
Area for donning and dossing
Positive and negative resident areas - No positives at this time.
Social distancing and masks being used

LPA observed the air conditioning working throughout the facility during this visit. The hot water temperature measured at 117.5*F. The temperature inside the facility measured on the thermostat is 72*F.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

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 PLACE INDEPENDENT LVG AND ASSISTED LVG	FACILITY NUMBER: 342700474
	VISIT DATE: 08/21/2020

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The fire extinguishers, carbon monoxide and smoke detectors were present in the facility. Facility also has a pull alarm system. LPA observed 2-day perishables and 7-day non-perishables. Facility is utilizing paper products for meals and snacks.

On 8/20/20, 31 residents were displaced due to an evacuation mandate during fire season. Those residents were relocated to this facility. LPA toured a random amount of shared rooms and did not observe any health and safety concerns during this visit. During this visit the Health and Wellness Director, Richard Remigio of Rancho Solano in Fairfiled, CA arrived to inform the residents to prepare to return home.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2020

LIC809 (FAS) - (06/04)

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