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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:41:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230427160250
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: 39DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bailey LeachTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Facility is not following resident's prescribed diet
Facility did not notify POA of hospitalization
INVESTIGATION FINDINGS:
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3
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5
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7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with business office director Bailey Leach and explained the purpose of the visit.

This investigation consisted of interviews with staff and a resident, review of facility records and review of resident records.

LPA Moleski reviewed an internal incident report regarding a fall suffered by R1 on 9/13/22 and an external incident report faxed to the Community Care Licensing Division (CCLD) on 9/16/22. The internal report states, under a section titled “Name of family member notified”: “Resident did not want to notify daughter. Told med tech & care giver. Daughter is out of state.” The internal report indicates that R1 was taken to the hospital for treatment.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 27-AS-20230427160250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG
FACILITY NUMBER: 342700474
VISIT DATE: 09/14/2023
NARRATIVE
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The external incident report does not note any contacts made with family members. Under a section titled “Agencies/individuals notified,” the author of the report only indicated that CCLD was notified. Under a section titled “Explain what immediate action was taken (include persons contacted),” the incident report states that the resident was evaluated by a staff member and emergency responders were called. The report does not state any further contacts were made. LPA Moleski interviewed a former executive director (ED1), who indicated that, to his knowledge, no report was made to R1’s family members. R1’s power of attorney (POA) said she was not notified by the facility of the incident. LPA Moleski reviewed a random sampling of four incident reports from August and September 2022 from this facility, including another incident report involving R1, and found that four of these reports identified a responsible party who was contacted. During interviews, a former executive director (ED2) and two former staff members (S3, S8) were unsure if notification was made to R1’s POA.

In interviews, ED1 said R1 was given food items contrary to R1’s prescribed diet, such as high-sugar foods. Another former executive director, (ED2) said the same. Two of two dining staff members interviewed (S5, S6) also said R1 was given food items contrary to R1’s prescribed diet, such as dairy products and high-sugar foods. Meal tickets for R1 reviewed by LPA Moleski often included requests for creamer. During an interview, R1 said she was served dairy products. R1’s LIC 602 dated 12/16/22 states that R1 is allergic to milk and milk products, among other things. R1’s functional needs assessment, dated 12/22/22, indicates that R1 needed a diabetic diet.

The department has determined the following as it relates to the allegations that the facility is not following resident’s prescribed diet and that the facility did not notify POA of hospitalization:

Based on interviews and review of facility records, the above allegations are SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87211(a)(1)(B) and 87555(b)(7). An exit interview was held with Leach. Appeal rights and a copy of this report were left with Leach.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230427160250

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: 39DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bailey LeachTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not adequately staffed
Facility does not respond to call pendants timely
Facility did not ensure resident safety resulting in serious injuries
False statement
Facility did not provide explanation of increase in rent to POA
Facility did not ensure resident received instructions during fire drill
INVESTIGATION FINDINGS:
1
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3
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5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with business office director Bailey Leach and explained the purpose of the visit.

This investigation consisted of observation, interviews with residents, staff, and a resident’s power of attorney (POA), interviews with two former executive directors, an interview with an ombudsperson, and review of resident records and facility records.

During the course of this investigation, LPA Moleski inspected the rooms where R1 lived. LPA Moleski did not observe fall risk hazards present in these rooms. LPA Moleski reviewed an internal incident report regarding a fall suffered by R1 on 9/13/22. According to the internal incident report, the fall was unwitnessed and took place in R1’s room.

[continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 27-AS-20230427160250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG
FACILITY NUMBER: 342700474
VISIT DATE: 09/14/2023
NARRATIVE
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LPA Moleski reviewed an external incident report that was faxed to the Community Care Licensing Division on 9/16/22. According to this report, R1 was walking to the couch in the living room of R1’s apartment and fell. According to this report, R1 was not wearing a call button pendant at the time of the fall. LPA Moleski interviewed a staff member (S3) who responded after R1’s fall. S3 said there weren’t any fall risk hazards present in R1’s room at the time.

LPA Moleski interviewed seven residents (R2-R8). R2 said there was adequate staffing but call response times were an issue. R4 expressed concerns regarding staffing and call response times. R7 said there was adequate staffing when staff are available, but when staff call out there are not enough staff to fill in. R7 did not voice concerns regarding call button response times. R3, R5, R6, and R8 did not express concerns regarding the current levels of staffing or call button response times. LPA Moleski interviewed four staff members regarding staffing levels. S3 and S4 did not voice concerns regarding staffing or call button response times. S5 and S6 did not voice concerns regarding staffing. LPA Moleski reviewed call button response times recorded for the rooms R1 lived in. The average response times for R1’s rooms were all below five minutes.

LPA Moleski interviewed two former executive directors (ED1, ED2) regarding contacts made with an ombudsperson. Both ED1 and ED2 said they were not aware of any request to forward information to an ombudsperson. LPA Moleski interviewed an ombudsperson, who was not aware of any such request. LPA Moleski reviewed an email between ED2 and R1’s power of attorney (POA) dated 9/1/22, in which ED2 provided a phone number in response to a request for contact information for the ombudsman’s office.

LPA Moleski reviewed a letter addressed to R1 and R1’s POA, dated 8/31/22. The letter describes an increase in rent prices and provides an explanation for the increase. According to the letter, the increase was to go into effect as of November 1, 2022. An address was listed at the top of this letter. During an interview, R1’s POA said this was a mailing address for R1 and R1’s POA. R1’s POA said they never received the letter.

[continued on 9099-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 27-AS-20230427160250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG
FACILITY NUMBER: 342700474
VISIT DATE: 09/14/2023
NARRATIVE
1
2
3
4
5
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8
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While inspecting R1’s room on 5/12/23, LPA Moleski observed posters affixed to the interior of R1’s apartment door. The posters contained information regarding fire drills. The posters direct the reader on what to do in the case a fire alarm goes off. If a fire alarm is set off, residents are to stay in their room if safe and await further instructions from staff, according to this poster. LPA Moleski interviewed a former executive director (ED1) regarding further instructions in the event that staff do not provide further instructions. ED1 said residents were given further information at three town hall meetings. LPA Moleski reviewed town hall meeting notes for meetings held on 1/26/23, 2/23/23, and 3/23/23. The notes indicate that fire drill instructions were discussed during each of these meetings. ED1 said that, during the January and February meetings, residents were instructed to consider the situation all-clear if there are no further instructions.

The department has determined the following as it relates to the allegations that the facility is not adequately staffed, that the facility does not respond to call pendants timely, that the facility did not ensure resident safety resulting in serious injuries, false statement, that the facility did not provide explanation of increase in rent to POA, and that the facility did not ensure resident received instructions during fire drill:

Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was held and a copy of this report was left with Leach.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Vincent Moleski
COMPLAINT CONTROL NUMBER: 27-AS-20230427160250

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: 39DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bailey LeachTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not addressing physical plant problems
Facility is not providing training for resident transfers
Facility is not reporting incidents to CCL
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with business office director Bailey Leach and explained the purpose of the visit.

This investigation consisted of observation, staff interviews and review of facility records.

During the course of this investigation, LPA Moleski visited the facility five times, not including today’s visit. LPA Moleski did not observe any physical plant deficiencies during these visits, including in the rooms where R1 used to live. LPA Moleski observed a staff member (S3) testing a vacuum in one of these rooms, and observed that the power was unaffected by the test.

[continued on 9099-C]
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 27-AS-20230427160250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG
FACILITY NUMBER: 342700474
VISIT DATE: 09/14/2023
NARRATIVE
1
2
3
4
5
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During an interview, S7 said the breaker flipped in this room once or twice due to the devices that were plugged in. S7 said staff were directed to utilize another outlet and had no issues afterward. LPA Moleski reviewed an incident report from this facility that described an incident on 8/8/22 wherein a water heater leaked into R1’s bedroom. The incident report describes steps taken by this facility to address the leak. LPA Moleski inspected the room where the leak occurred and observed no physical plant deficiencies.

LPA Moleski reviewed staff transfer training records dated January 25, 2023 and an all-staff training sign-in sheet dated April 26, 2023.

LPA Moleski reviewed an incident report regarding a fall suffered by R1 on 9/13/22. The incident report was received by the Community Care Licensing Division (CCLD) via fax as of 9/16/22.

The department has determined the following as it relates to the allegations that the facility is not addressing physical plant problems, that the facility is not providing training for resident transfers, and that the facility is not reporting incidents to CCLD:

Based on observation, review of facility records, review of licensing records, and staff interview, the above allegations are UNFOUNDED. A finding that the complaint allegations are unfounded means the allegations are false, could not have happened or are without a reasonable basis.

An exit interview was held and a copy of this report was left with Leach.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 27-AS-20230427160250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87211(a)(1)(B)
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Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision."

This requirement was not met as evidenced by:
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Licensee agrees to conduct an in-service staff training on reporting requirements. Licensee further agrees to send LPA Moleski a copy of a sign-in sheet for this training by the POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, R1's POA was not notified after R1 suffered a serious injury at this facility, which poses a potential health and safety risk.
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Type B
09/29/2023
Section Cited
CCR
87555(b)(7)
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Food Service: "(b) The following food service requirements shall apply:

(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided."

This requirement was not met as evidenced by:
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Licensee agrees to conduct an in-service staff training on food service requirements. Licensee further agrees to send LPA Moleski a copy of a sign-in sheet for this training by the POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interviews, R1 was provided food contrary to doctor's orders, which poses a potential health and safety risk.
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8