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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700474
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:38:15 PM


Document Has Been Signed on 10/05/2023 02:38 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:BRITTANY A ANDREWSFACILITY TYPE:
740
ADDRESS:6350 RIVERSIDE BLVDTELEPHONE:
(916) 427-1133
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:48CENSUS: 36DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bailey Leach, Business Office DirectorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/5/23 at 10am to conduct an investigation of a medication error. LPA met with Bailey Leach, Business Office Director and stated the purpose of the visit. Community Care Licensing (CCL) received an Unusual Incident/Injury Report incident report (LIC624-SIR) dated 9/15/23 regarding resident #1 (R1). The SIR indicated that on 9/12/23, R1 received medication that should have been administered at 11:30am but instead it was administered at 2pm. R1 should have received eye drops during the 2pm medication pass but did not receive that. In essence, Staff #1 (S1) inadvertently switched the medications and times that should have been administered. The responsible parties of R1 and S2, was present with R1 at the time when the medications were questioned by S2. S2 contacted the doctor and placed R1 on 72hr alert charting. There were no adverse reactions to the medication error. S1 was removed from the Medication Technician position and will be re-trained with shadowing.

LPA interviewed S1-S3, R1, and responsible parties of R1. 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 Administrator designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

Exit interview conducted and a copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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Document Has Been Signed on 10/05/2023 02:38 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
CCR
87465(c)(2)

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Incidental Medical and Dental Care
If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
Once ordered by the physician the medication is given according to the physician's directions.
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Licensee has submitted proof that additional training was provided to S1.

POC Cleared prior to today’s visit
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This requirement is not met as evidenced by: Medication was not administered as prescribed to R1 Based on documentation and interviews which confirmed the medication error occurred.
This violation poses a potential health and safety risk to residents in care.
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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: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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