342700474-6-18-2021-27-AS-KHOS-C49KMB-20210623080116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 06/18/2021
Date Signed: 06/18/2021 02:41:50 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
01/11/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210111132835

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:	06/18/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Frances Santillan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff do not keep the facility free of trash
Facility handicap button is in disrepair
Staff do not provide activities for residents
Staff do not provide transportation for residents as agreed
Residents are prohibited from having visits

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.

Unsubstantiated

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: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

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-20210111132835

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: 06/18/2021

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/18/2021 at 1:00pm to conclude the complaint investigation. LPA met with Frances Santillan and discussed the purpose of the visit.
Regarding allegation "Staff do not keep the facility free of trash", LPA observed the laundry room area where the trash is kept in a large trash barrel from each resident room to be emptied into the outside Trash bin during each work shift. LPA observed there was 1 housekeeper out ill for 1 week, however, the maintenance would assist the caregivers in assuring the trash was emptied from each room and the trash barrel into the trash bin outside for pickup. In addition, 1 more housekeeper was hired the next day prior to CCL visit and after the complaint was written and 1 other was hired within 7 days. Allegation deemed UNSUBSTANTIATED
Regarding allegation "Facility handicap button is in disrepair", LPA observed during the previous visit that the handicap button to allow entry and exit was actually working. However, the cement beneath it needed to be reconstructed to allow both doors to open completely as it has in the past. LPA observed an invoice for concrete grinding that was dated 1/20/21. The facility was aware and scheduled a visit from the company to assess the problem and fix it. Allegation deemed UNSUBSTANTIATED
Regarding allegation "Staff do not provide activities for residents", LPA observed a monthly activities schedule for the year. Activities were conducted during Covid per the CDC and CCL Guidelines. Allegation deemed UNSUBSTANTIATED
Regarding allegation "Staff do not provide transportation for residents as agreed", LPA observed that transportation was limited during Covid per the CDC and CCL Guidelines. Allegation deemed UNSUBSTANTIATED
Regarding allegation "Residents are prohibited from having visits", on the previous visit 1/16/21, LPA observed a sign that was posted at the entrance gate indicating as of 11/11/20 there will be no visitors at which time the sign was removed. LPA received a copy of a general letter that was given to residents indicating visitors are allowed dated 1/13/21. Between the dates of 11/11/20 and 1/16/21 the no visitors sign was posted to not allow visitors. However, a letter stating visitation was allowed was given to the residents on 1/13/21. Based on a review of the Covid 19 call from Community Care Licensing (CCL) it was documented that the last covid positive was in December 2020, a guidance was issued to limit visitation during an outbreak. The last clearance call from CCL was on 1/1/21 which indicates that after the last covid clearance the facility did not remove the signage but issued a letter approving visitation. Allegation deemed 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, a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2021

LIC9099 (FAS) - (06/04)

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