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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 10/24/2022
Date Signed: 10/24/2022 04:02:32 PM


Document Has Been Signed on 10/24/2022 04:02 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:ROBERT COEFACILITY TYPE:
740
ADDRESS:6350 RIVERSIDE BLVDTELEPHONE:
(916) 427-1133
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:48CENSUS: 85DATE:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Robert CoeTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/24/22 at 1:00p to conduct a Case Management visit. LPA met with Robert Coe and stated the purpose of the visit. Community Care Licensing (CCL) received a incident report (LIC624) on 3/25/2022 regarding a resident stating that a caregiver was physically abusive.

S1 stated R1 did not report the persons name but said during the night of the funeral the pendant couldn't be located and staff came in and punched the stomach. R1 stated to S1 the facility should know what's happening in the facility there is no need to report things. S1 stated that the funeral was at least 1 month prior to the report of abuse. R1 refused to be interviewed and stated that happened 1 year ago under a different management.

Based on the information reviewed and obtained, although the allegation may have happened or is valid,
there is not a preponderance of the evidence to prove that the alleged abuse occurred and that the facility is at fault for any deficiencies regarding Title 22 regulations.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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