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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:16:49 PM


Document Has Been Signed on 08/30/2023 04:16 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: 40DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bailey Leach, Business Office DirectorTIME COMPLETED:
04:30 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 8/30/23 at 11am to obtain additional information regarding a Special Incident report (SIR-LIC624) received by Community Care Licensing (CCL) on 8/28/23. The SIR stated that a medication error occurred where as resident #1(R1) received R2's medication.

LPA interviewed Staff #1 (S1)-(S3) and (R1)-(R2) and reviewed the medication process with S2 during this visit.

Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met.

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 Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, 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: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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 2


Document Has Been Signed on 08/30/2023 04:16 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: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2023
Section Cited
CCR
87465(j)

1
2
3
4
5
6
7
Incidental Medical and Dental Care
In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring ... assisting residents as needed with self-administration of medications...
1
2
3
4
5
6
7
Licensee has submitted proof that a review of medication administration practices was conducted.

POC Cleared prior to todays visit
8
9
10
11
12
13
14
This requirement is not met as evidenced by: medication that belonged to R2 was administered to R1 and there was no adverse reaction Based on documentation which confirmed the medication error occurred
This violation poses an potential 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

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: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2