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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003494
Report Date: 03/07/2024
Date Signed: 03/07/2024 10:44:14 AM


Document Has Been Signed on 03/07/2024 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:GREEN FIELD HAVENFACILITY NUMBER:
347003494
ADMINISTRATOR:KONONOV, LARISAFACILITY TYPE:
740
ADDRESS:3620 WINONA WAYTELEPHONE:
(916) 482-1314
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator- Larisa KononovTIME COMPLETED:
10:50 AM
NARRATIVE
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On 03/07/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator Larisa Kononov and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to the kitchen, dining room, residents bedrooms, bathrooms, common areas and backyard. LPA observed the facility to have sufficient food supplies for seven (7) day non-perishable and two (2) day perishable. LPA observed toxins, knives and centrally stored medications to be locked and inaccessible to residents in care. All required Licensing posters are present in common areas in the facility. Hot water temperature was measured at 117.2 degrees Fahrenheit at the bathroom sink, which is within the required range of 105 to 120 degrees. The temperature in the facility was 71 degrees. Fire extinguishers was last inspected on 12/06/23.

LPA conducted a file review of three (3) resident files and two (2) personnel files. LPA observed two (2) personnel files to be incomplete with no annual training.

LPA requested a copy of the current liability insurance to be sent to LPA Ratajczak by 03/21/24.

LPA completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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Document Has Been Signed on 03/07/2024 10:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GREEN FIELD HAVEN
FACILITY NUMBER: 347003494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files being incomplete with annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
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Licensee will conduct an annual training with staff by the POC due date and submit to LPA Ratajczak a list of topics covered as well as staff signatures indicating which staff has completed the training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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