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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701136
Report Date: 01/09/2023
Date Signed: 01/09/2023 12:20:51 PM


Document Has Been Signed on 01/09/2023 12:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GREENHAVEN VILLA RCFEFACILITY NUMBER:
342701136
ADMINISTRATOR:DURAN, JENNYLINDFACILITY TYPE:
740
ADDRESS:7465 GREENHAVEN DRIVETELEPHONE:
(916) 266-3030
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
01/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jennylind DuranTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/9/23 at 11:45AM. The Administrator certificate expires 5/3/2024 for Jennylind Duran.

LPA met with Jennylind Duran, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 may be bedridden. Hospice Waiver approved for 6 to receive hospice care services. There is 1 resident receiving hospice care services at this time.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA observed rooms to have required furniture. LPA observed residents during this visit.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which shall be maintained on the premises. The temperature inside the facility was observed to be at 70*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.1*F which is within the required range of 105-120*F.
LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air, and pull alarm system in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308)
Liability Insurance
Administrator Certificate-Updated
Personnel Report (LIC500)

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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