342700474-6-22-2021-27-AS-SRIN-C4C4JA-20210625190824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:35:33 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
04/12/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210412131926

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: 38	DATE:	06/22/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Frances Santillan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

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.

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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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-20210412131926

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: 06/22/2021

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/22/2021 at 11:00am to conclude the complaint investigation. LPA met with Frances Santillan and discussed the purpose of the visit.

Regarding allegation "Staff mismanaged resident's medication", LPA interviewed staff and reviewed the MARs and medication prescriptions during this visit. The investigation revealed that there was a medication error for resident #1 (R1). R1 missed a dose of Insulin named "Lantus" because the staff was unable to locate the insulin. The Administrator Jo Franklin and Nurse Yvonne Holms submitted an incident report to Community Care Licensing (CCL) on 10/9/2020 indicating the medication error and in-service training of staff.

Based on interviews and documentation review 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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210412131926

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: 06/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/22/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care Once ordered by the physician the medication is given according to the physician's directions.	1 2 3 4 5 6 7	Administrator Frances Santillan and Nurse Angela Maynard conducted medication inservices on 5/11/21, 5/13/21, 6/3/21, and 6/17/21. LPA observed signed documentation. POC cleared prior to todays visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed that R1 missed a dose of insulin. Based on confirmation from S1 who stated the insulin was not able to be located until the next morning. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC9099 (FAS) - (06/04)

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