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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:25:34 PM


Document Has Been Signed on 09/23/2022 12:25 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: 35DATE:
09/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Regina Farinias, Marketing Director TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/23/22 at 9:30a to obtain information regarding an incident report submitted to Community Care Licensing (CCL) regarding Resident #1 (R1). LPA met with Regina Farinias, Marketing Director and stated the purpose of the visit.

The incident report indicated that the police arrived to obtain information for resident #1 (R1) as R1 was in a car accident on or about 9/15/22.

LPA requested and obtained a copy of R1's Identification and Emergency Information (LIC601) dated 2/4/22, Physician report(s) (LIC602A) dated 1/20/22, 4/15/22, 4/27/22, Preplacement Appraisal (LIC 603) dated 2/4/22, Drivers License, and Out patient medications list.

LPA conducted interviews of staff #1 (S1-S3) and R1 during this visit.

A review of documentation provided revealed that R1's physician reports all indicate that R1 is able to leave facility unassisted with supervision. It also indicates that R1 is diagnosed with Mild Cognitive Impairment (MCI). The Preplacement Appraisal indicates resident can be a bit confused at times.

The investigation revealed that R1 was driving alone and had an accident with no major injuries. Although R1 continued to drive a personal vehicle, the LIC602 indicates that R1 needed supervision.

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. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Staff was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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Document Has Been Signed on 09/23/2022 12:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2022
Section Cited

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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...deterioration of mental ability...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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This requirement is not met as evidenced by: R1 having a car accident while driving alone.
Based on interviews confirming R1 was driving alone facility did not ensure supervision as stated on LIC602.
This violation 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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