342700474-11-3-2021-27-AS-KHOS-C8LLCW-20211109073903

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700474
Report Date: 11/03/2021
Date Signed: 11/03/2021 03:40:42 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
09/13/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210913100845

FACILITY NAME:	GREENHAVEN PLACE INDEPENDENT LVG AND ASSISTED LVG		FACILITY NUMBER:	342700474
ADMINISTRATOR:	FRANCES SANTILLAN		FACILITY TYPE:	740
ADDRESS:	6350 RIVERSIDE BLVD		TELEPHONE:	(916) 427-1133
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	48	CENSUS: 29	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Frances Santillan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff intimidate resident(s).
Residents are not being provided adequate food service.
Facility is not conducting fire drills as required.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the complaint investigation on the above mentioned allegations on 11/3/21 at 9:30am. LPA met with Francis Santillan and stated the purpose of today’s visit. LPA conducted interviews of Staff #1 (S1-S7) and Resident #1 (R1), POA, and Private Caregiver (PC) of R1 during this visit.

Regarding allegation "Staff intimidate resident(s)", LPA was told by R1 with a raised voice that LPA could not be understood while using the mask. LPA spoke louder and asked the PC if R1 wore a hearing aid. The PC put in the hearing aid for R1, and R1 was able to understand LPA during interview. The Power of Attorney for R1 stated that everyone has to speak louder due to R1 being hard of hearing. R1 stated a creamer was used by R1 in a soup to make a cream of tomato soup and no one restricted R1 from doing so. R1 stated that staff has not been intimidating. LPA conducted interviews of S1-S7. The investigation revealed that all staff, R1, POA, and Administrator concur that staff are not intimidating the residents.

Unfounded

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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-20210913100845

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: 11/03/2021

NARRATIVE

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Regarding allegation "Residents are not being provided adequate food service" In reviewing the Diet Clarification Form dated 6/3/21, R1 can self manage diet and the Physician report dated 6/3/21 indicates R1 is not on a special diet. The facility has a Dietician and a Dining Services Director who over sees the menus and the dining staff. LPA observed there are sample entrees prepared for residents to see visually and there are alternatives and off the menu items offered as well. In addition, a weekly menu is given to all residents to assist in their decision for meals. Residents are able to complete a room service delivery slip or verbalize their preferences to staff. LPA conducted interviews, obtained information, and observed that this facility utilizes a computerized system that will not allow a printed menu with too many carbohydrates, too much sodium, or calories on any given day. It is set up to only allow balanced meals to be added to the menus. If an unbalanced menu occurs then the system flags red and will not print out the menu until the menu is corrected.

Regarding allegation "Facility is not conducting fire drills as required" LPA conducted interviews and observed the training documents that were signed by each staff in attendance for the in-services. LPA received documentation of drills and in-services conducted from 3/24/21 through 9/22/21. The training's were on the following topics: Verbal Fire Drill, Elopement Drill, Behavioral Management, Medication, Resident Rights, Mandated Reporting, and Emergency Preparedness Drills and Exercise that was conducted. The investigation revealed that the materials are reviewed and the trial run is conducted with staff to ensure knowledge on tasks and how to assist residents efficiently.

Based on interviews and observation of documentation, the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. An exit interview was conducted, and 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: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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