347003494-10-29-2024-59-AS-LCRR-DAKPQE-20241031113101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003494
Report Date: 10/01/2024
Date Signed: 10/29/2024 10:56:16 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20240815091717

FACILITY NAME:	GREEN FIELD HAVEN		FACILITY NUMBER:	347003494
ADMINISTRATOR:	KONONOV, LARISA		FACILITY TYPE:	740
ADDRESS:	3620 WINONA WAY		TELEPHONE:	(916) 482-1314
CITY:	NORTH HIGHLANDS	STATE: CA	ZIP CODE:	95660
CAPACITY:	6	CENSUS: 5	DATE:	10/01/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Larisa Kononov, Licensee		TIME COMPLETED:	09:56 AM

ALLEGATION(S):

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Staff are overmedicating resident in care.
Licensee does not ensure that resident(s) are provided with activities while in care.
Staff limit visitations with resident in care.

INVESTIGATION FINDINGS:

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Amend: to make public-On October 1, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-0815091717. LPA met with Larisa Kovonov, Administrator and informed her the reason for the visit. The department received a complaint alleging facility staff are over medicating resident while in care, Licensee does not ensure that resident(s) are provided with activities while in care and Staff limits visitations with resident in care.

During the investigation process interviews and a records review was initiated. LPA reviewed R1s medical documentation and physician report and needs and services plan. R1’s son is the Power of Attorney.

LPA investigated the allegation, “Staff are over medicating resident while in care.” LPA reviewed R1s PRN Medication Records and medical provider’s medication list. Documents obtained show that all current medications were administered and logged correctly for R1, per their doctor’s orders. Interview indicated staff were not over medicating R1 and R1 expressed no concerns with medication administration.
Allegation Unfounded.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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 59-AS-20240815091717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/01/2024

NARRATIVE

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9099-C...
LPA observed residents participating in activities during today's visit and on. LPA also interviewed residents and all but one stated there were activities. LPA learned the one resident that stated there are none does not choose to participate in activities. LPA observed two separate activity calendars. ALLEGATION UNFOUNDED.

LPA investigated the allegation staff limits visitations with resident in care. R1 told LPA, R1 doesn’t want to visit with their family. R1 also said when their family comes to visit, R1 doesn’t make eye contact or speak with their family. R1 stated the facility is talking good care of him and gets showers and shaves daily. ALLEGATION UNFOUNDED.

This agency has investigated the complaint alleging facility staff are over medicating resident while in care, Licensee does not ensure that resident(s) are provided with activities while in care and staff limits visitations with resident in care. Based on LPA's observations and interviews the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy given to Larisa.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

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