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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 03/10/2022
Date Signed: 03/10/2022 04:11:17 PM


Document Has Been Signed on 03/10/2022 04:11 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:GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVGFACILITY NUMBER:
342700474
ADMINISTRATOR:FRANCES SANTILLANFACILITY TYPE:
740
ADDRESS:6350 RIVERSIDE BLVDTELEPHONE:
(916) 427-1133
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:48CENSUS: 33DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Frances SantillanTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to obtain information regarding an incident report submitted to Community Care Licensing (CCL) regarding Resident #1 (R1). LPA met with Administrator (Adm) Frances Santillan and stated the purpose of the visit. LPA conducted interviews of Adm, R1, and Police Department during this visit.
LPA obtained a copy of R1's Identification and Emergency Information (LIC601), Release of Client/Resident Medical Information (LIC 605), Physician report (LIC602A) dated 7/12/21, Resident Emergency Form dated 3/10/22, Resident Emergency Form dated 7/22/21, Preplacement Appraisal (LIC 603), Durable Power of Attorney (POA) dated 8/1/2007, email between Adm and R1's emergency contact dated 1/21/22, A letter indicating to add a person to R1's contact list to call for emergencies that did not include a date or signature, a copy of the SOC341 and Incident Report submitted to CCL and Long Term Care Ombudsman (LTCO) on 1/21/22, an email between Adm and R1's emergency contact dated 1/19/22 indicating a concern about charges on R1's bank card $2500, on 1/5/22, $3620 (twice) on 1/16/22, Police report dated 1/21/22 filed online, POA for Health Care with Advance Heath Care Directives dated 1/26/22, email between Adm and R1's emergency contact dated 2/8/22 indicating no longer able to pay bills for R1 and has been removed from access. Resident Evaluation dated 2/21/22, a fax to R1's Primary Care Physician indicating very confused requesting a video appointment dated 2/22/22, a fax to CCL indicating a call was received from R1's bank during this visit.

A review of R1's physician report indicates that R1 is able to manage own cash resources and able to leave facility unassisted. It also indicates that R1 is confused and/or disoriented.

The investigation revealed that a review of all documents mentioned above, the facility has not violated any Title 22 regulations and is working with Adult Protective Services (APS), PCP, and Law Enforcement to ensure R1 remains safe physically and monetarily while residing in the facility.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. 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: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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