342700474-6-14-2021-27-AS-SRIN-C42QL6-20210616121525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 06/14/2021
Date Signed: 06/14/2021 02:27:15 PM

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
12/15/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20201215095808

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: 35	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Frances Santillan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff failed to safeguard resident's Financial property resulting in grand theft.

INVESTIGATION FINDINGS:

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Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion/runny nose, Nausea or vomiting, and Diarrhea. Have any individuals tested positive for COVID-19 with a laboratory confirmed test? Have any individuals been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a “No” answer to all the above-mentioned questions. See 9099C for continuation...

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 4

Control Number 27-AS-20201215095808

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: 06/14/2021

NARRATIVE

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9099 Continued...

Licensing Program Analyst (LPA) Victoria Brown arrived on 6/14/21 at 9am to conclude the investigation of the complaint. LPA met with Frances Santillan and stated the purpose of the visit. LPA conducted an initial 10 day visit on 12/15/2020. At which time, LPA requested the following: Physician Report (LIC602), Admission Agreement, Identification and Emergency Information (LIC601), any documents of facility investigation, Appraisal/Needs and Services Plan (LIC625), Centrally Stored Medication and Destruction Record (LIC622), Resident Personal Property and Valuables (LIC621), Personnel Report (LIC500) along with staff work schedules and updated/current contact information to include staff that are no longer working for the facility.

LPA received information and evidence that Staff #1 (S1) misappropriated R1's finances over the amount of $14,000 using R1's bank card. LPA reviewed all documents requested, including but not limited to, the Sacramento Police Report.

Based on interviews, and police report, the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted and a copy of the report was given. See 9099D for continuation...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20201215095808

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2021 Section Cited CCR 87405	1 2 3 4 5 6 7	87405(b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.	1 2 3 4 5 6 7	Licensee shall ensure Administrator is well versed on Tite 22 regulations in performing administrative duties. A letter of confirmation shall be submitted by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed that Administrator allowed S1 to gain access to R1's personal finances. Based on confirmation from police report Administrator allowed S1 access to R1's finances. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 06/14/2021 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	Licensee shall ensure all staff has completed an inservice for resident rights and mandated reporting. Confirmation of the inservice completion with signatures shall be submitted to CCL by 6/21/2021.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed that S1 used R1's funds for personal use. Based on confirmation from police report S1 used R1's funds for personal use. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20201215095808

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2021 Section Cited HSC 1569.58(a)(5)	1 2 3 4 5 6 7	Persons prohibited from being a licensee, owning beneficial interest in licensed facility, or holding certain positions or employment; grounds; notice; removal; appeal; petition for reinstatement The department may prohibit any person ... who has done any of the following: Engaged in acts of financial malfeasance concerning... but not limited to, improper use or embezzlement of client moneys...	1 2 3 4 5 6 7	Licensee shall remove S1 from the premisis. POC Cleared prior to todays visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed that Administrator allowed S1 to gain access to R1's personal finances. Based on confirmation from police report Administrator allowed S1 access to R1's finances. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 06/14/2021 Section Cited CCR 87777(a)	1 2 3 4 5 6 7	Exclusions (a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59.	1 2 3 4 5 6 7	Licensee shall remove S1 from the facility staff roster. POC Cleared prior to todays visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed that Administrator requested to remove S1 from the facility roster. Based on confirmation the Administrator S1 has been removed from the facility roster. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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