342700474-5-6-2021-27-AS-KHOS-C2WMLX-20210511094304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 05/06/2021
Date Signed: 05/06/2021 11:10:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/07/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210107095944

FACILITY NAME:	GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG		FACILITY NUMBER:	342700474
ADMINISTRATOR:	JO FRANKLIN		FACILITY TYPE:	740
ADDRESS:	6350 RIVERSIDE BLVD		TELEPHONE:	(916) 427-1133
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	48	CENSUS: 36	DATE:	05/06/2021
		UNANNOUNCED	TIME BEGAN:	10:21 AM
MET WITH:	Frances Santillan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident decline due to neglect.
Resident not getting needs met.
Staff did not assist the resident in staying in touch with the family.
Resident room was not cleaned.
Resident's belongings are missing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele-visit on 5/6/2021 at 10:20am due to COVID-19 and pre-cautionary measures. LPA met with Frances Santillan and discussed the purpose of the call and the elements of this type of visit. This visit is being conducted to conclude the investigation of the complaint allegation(s).
Regarding allegation, “Resident decline due to neglect”. During interviews, S1 stated that Resident #1 (R1) was reminded to drink water but liked to drink milk and that water bottles were put on the table next to the couch. S5 stated every week it was observed that R1 had little water bottles around the home, by the bed, in the bathroom and in the refrigerator.
Regarding allegation, “Resident not getting needs met”. During interviews, S1 stated that R1 may have used pads but no diapers. S1 stated R1 was not in bed with only a diaper and that R1 would use the pendent to call for assistance to bathroom. S5 stated R1 would wear a gown only to be easier to go to the bathroom. R1 would dress self but mostly with help by a caregiver. S5 also stated that R1 was always out of bed, dressed and sitting on the sofa during the weekly room cleaning and that R1 would walk using the walker.

Unsubstantiated

Estimated Days of Completion: 190

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210107095944

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/06/2021

NARRATIVE

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Regarding allegation, “Staff did not assist the resident in staying in touch with the family”. S1 stated they were calling the family when needed. S1 stated that R1 had a cell phone and was able to answer it but needed assistance to dial out. Before covid the visitors would stay on the balcony. Then they would visit on the outside in the parking lot where there is a table with an umbrella. R1 was in getting up and ready every day. S2 stated the family would call the front desk when R1 was not answering the phone or when R1’s phone was not working.
Regarding allegation, “Resident room was not cleaned”. During interviews, S1 stated that caregivers and housekeeping would empty garbage on each shift, clean the refrigerator of any expired foods and milk, and fruits. S5 stated that R1’s room was on the schedule to be cleaned weekly. The staff duties were to lightly dust, clean the dishes, the floors, and bathroom. The refrigerator was not a designated duty, however, if the resident requested assistance it would be given.
Regarding allegation, “Resident's belongings are missing”. During interviews, S1 stated that R1 never complained about anything missing. S1 did not remember if R1 wore jewelry or even if R1 had a Jade charm and gold necklace because the focus was to complete the job. S3 did not remember if R1 wore jewelry but remembered management mentioning in a meeting that the family was looking for a Jade charm and necklace but couldn’t remember the date of the meeting or when it became missing. S5 did not remember seeing R1 wearing jewelry but the room was cleaned weekly and there were no knives or scissors observed only plastic utensils.
The investigation revealed that the Jade was located by the family in R1’s room but the necklace is allegedly still missing. LPA was also informed that R1 had Cutco knives and scissors that are missing. LPA observed pictures of R1 with a necklace however, the necklace did not include the Jade charm. During interviews, and a review of R1’s physician report dated 7/15/2020, LPA observed R1 had a diagnosis of Dementia. LPA also obtained information that Dove soaps were missing from R1’s room that were recovered by family during the time R1 was moving out of the facility. It was also mentioned that R1 was reassured that items were not missing by the family being present during times the room was being cleaned. LPA observed based on interviews and a picture of a knife conflicting information that a Cutco knife and/or Cutco scissors was missing. LPA did not observe a picture of R1 having scissors in the room.
Based on interviews conducted and lack of evidence the preponderance of evidence standards has not been met. The allegation(s) are UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Frances Santillan via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021

LIC9099 (FAS) - (06/04)

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