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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003614
Report Date: 10/22/2021
Date Signed: 10/22/2021 03:09:00 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: DATE:
10/22/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:30 AM
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An Office Meeting was held today in the Sacramento South Adult and Senior Care Regional Office via Microsoft Teams. This meeting was held due to the passing of the Co-Licensee.

Those present in the meeting are Regional Manager Krystall Moore, Licensing Program Manager Stephen Richardson, Licensing Program Manager Czarrina Camilon-Lee, Licensing Program Analyst(s) Victoria Brown, and Tung Truong, Co-Licensee Frances Kang, along with facility representatives Maria Kang, and Christine Aducayen-Kang.

Currently, Frances Kang is the sole member of the LLC and continues to have Control of Property and of the business. Frances Kang stated there are no changes to the operations of the facility or the finances.

To remain in substantial compliance Frances Kang agreed to submit the following:
-Updated Secretary of State documents, the intent of Frances Kang is to change the entity (LLC) members.
-Change of Ownership Application Part A & B-to be submitted by 11/30/21
*The LIC281 can be downloaded from on-line for application instructions
-A copy of the death certificate as soon as it is obtained
-A letter to each resident and/or responsible party regarding the intent

Frances was advised that should anything discussed to change CCL will be contacted immediately to ensure the health and safety of the residents continue.

Frances was advised that health and safety visits will be conducted until the CHOW application is submitted. Also, if there are any concerns or questions to contact LPA(s) Victoria Brown and/or Tung Troung.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Frances Kang via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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