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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005075
Report Date: 05/28/2021
Date Signed: 06/02/2021 08:52:52 AM

Document Has Been Signed on 06/02/2021 08:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:COMFORTS OF HOME GREENHAVEN RCFEFACILITY NUMBER:
347005075
ADMINISTRATOR:CHAN, JACQUELINEFACILITY TYPE:
740
ADDRESS:6936 GLORIA DRIVETELEPHONE:
(916) 329-8151
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jesusa Pasca, CaregiverTIME COMPLETED:
03:10 PM
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On 05/28/2021, Licensing Program Analyst (LPA) V. Brown spoke with facility regarding facility risk assessment questions. Facility confirmed no staff or clients have experienced symptoms within the last 10 days. At 1:30pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Caregiver, Jesusa Pasca and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. First aid kit was observed to be complete. Fire drill was last conducted on 03/14/2021. LPA observed mitigation plan completed.

LPA observed the following deficiencies:
- LPA observed fire extinguisher last serviced May 09, 2019. Civil penalty assessed.
- LPA observed uncovered plugs located in the dining room.

Report continues on 809C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2021
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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Document Has Been Signed on 06/02/2021 08:52 AM - It Cannot Be Edited


Created By: Treana White On 05/28/2021 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMFORTS OF HOME GREENHAVEN RCFE
FACILITY NUMBER: 347005075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87303(a). LPA observed uncovered plugs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/11/2021
Plan of Correction
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Administrator agreed to cover plugs and submit proof by POC date.
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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/02/2021 08:52 AM - It Cannot Be Edited


Created By: Treana White On 05/28/2021 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMFORTS OF HOME GREENHAVEN RCFE
FACILITY NUMBER: 347005075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above 87202(a). LPA observed expired fire extinguisher which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2021
Plan of Correction
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Administrator agreed to purchase or service fire extinguisher and submit proof by POC date.

CIVIL PENALTY ASSESSED
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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2021


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COMFORTS OF HOME GREENHAVEN RCFE
FACILITY NUMBER: 347005075
VISIT DATE: 05/28/2021
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/11/2021:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC809 (FAS) - (06/04)
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