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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003614
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:00:04 PM

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:
347003614
ADMINISTRATOR:JENNYLIND DURANFACILITY TYPE:
740
ADDRESS:7465 GREENHAVEN DRTELEPHONE:
(916) 424-7292
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennylind DuranTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/21/21 at 12:00pm to conduct a health and safety check on the residents. LPA met with Jennylind Duran and stated the purpose of the visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The Administrator certificate for Jennylind Duran expires 5/3/22.

The facility is licensed for a capacity of 6 non ambulatory residents. Facility has a Hospice Waiver granted for 6. Currently, there are 2 residents receiving hospice services at this time. LPA observed residents and their rooms.

LPA observed 2 day perishables and 7 day non-perishables food items. LPA observed the LIC308 posted during this visit.

The hot water measured at 118.2*F which is within the required range of 105-120*F. The temperature inside measured at 75*F which is within the required range of 68-85*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air 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.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. 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: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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