<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:04:39 PM


Document Has Been Signed on 09/23/2022 01:04 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Regina FariniasTIME COMPLETED:
01:10 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
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/23/22 at 9:30a LPA met with Regina Farinias, Marketing Director and stated the purpose of the visit. LPA inquired about a Designation of Facility Responsibility (LIC308) and the staff was unsure of the document being requested.
On 9/13/22, LPA was informed that the Administrator would no longer be working at this facility. On 9/14/22, LPA received a call from the Corporate Office indicating a new Administrator would be hired. On the same date, LPA emailed the pertinent documents that would be needed to change the Administrator on record with the Department. On 9/21/22, LPA emailed Corporate Office inquiring about the documents. During todays subsequent visit, LPA received an email indicating the documents for a new Administrator will be provided to Community Care Licensing (CCL) by the week of 9/26/22. The email that was sent by LPA contained the following information:
Here is the information to change a administrator. Please ensure there is an LIC308 in effect.
Here is the information that need to be submitted to avoid a citation in the event that a change is necessary.
Please ensure the person is fingerprint cleared and associated to the facility through your Guardian account, and submit the documents mentioned below. At which time I can process the change. These documents are to be submitted as well as notification to the Department any time there is a change or intended change in the Administrator and/or Executive Director.
Administrator Certificate, Personnel Record (LIC501), Health Screening with TB (LIC503), CPR/First Aid, Criminal record statement (LIC508), -Designation (LIC308), -A letter from the Licensee appointing the person to be able to speak on behalf of the Licensee.
Updated Personnel Report (LIC500) showing the Administrator on schedule in the facility 40hrs per week
To date, the Department has not received for 10 days a Designation of Facility Responsibility (LIC308) nor documentation of an administrator with the supporting documents.

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)
Page: 1 of 2


Document Has Been Signed on 09/23/2022 01:04 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

1
2
3
4
5
6
7
Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Staff was unsure of the Designation form for who is in charge at this time.
Based on No LIC308 posted or made available and no Administrator either hired or on premisis.
This violation poses an immediate health, and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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)
Page: 2 of 2