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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:01:57 PM


Document Has Been Signed on 01/13/2023 03:01 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: 33DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Robert CoeTIME COMPLETED:
03:00 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 to conduct a Required - 1 Year visit on 1/13/23 at 11:45AM. LPA met with Robert Coe, Administrator and stated the purpose of todays visit.

LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. The facility has 1 residents receiving hospice care services at this time. Administrator Certificate expires 1/10/2025.

LPA observed and interviewed residents during this visit.

The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0*F during this visit which is within the required range of 105-120*F. LPA observed a random amount of rooms during this visit. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed 2-day perishables and 7-day non-perishables.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

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: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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 1