347005239-6-26-2020-27-AS-VBRN-BQXSM5-20200626135923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 06/26/2020
Date Signed: 06/26/2020 01:59:35 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 ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DALE MASTERS		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 49	DATE:	06/26/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Dale Masters		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an announced Tele-Office visit on 6/26/20 at 1:00pm due to COVID-19 and pre-cautionary measures. This meeting will be held using “Zoom”. Present in the meeting were Regional Manager Krystall Moore, Licensing Program Manager Stephenie Doub, Licensing Program Analyst Victoria Brown, Regional Vice-President Sonya Buchanan, Vice President of Clinical Services Kandice Alcorn, RN MSN, Barbara Rose, Health Services Director, and Executive Director Dale Masters. Krystall Moore discussed the purpose and elements of this type of call. It is to review the stipulation adopted on 6/18/2020 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The Stipulation was reviewed with representatives of FC Ranger OPS Greenhaven Estates; GH Senior Living who expressed their understanding. Items discussed at the meeting included, but not limited to: · Stipulation contents · Findings · Revocation: STAYED with Probation · Civil Penalty · Future Application for License, Registration, Certification or Approval · Licensure and Approval · Application Denial · Tolling of Probationary Period · Completion of Probation

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

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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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: GREENHAVEN ESTATES	FACILITY NUMBER: 347005239
	VISIT DATE: 06/26/2020

NARRATIVE

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· Violation of Stipulation Term
· Department's Authority
· Monitoring Fee
· Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims
· Severable terms
· Public records
· Signatures
· Counterparts
· Effective Date: (6/18/2020 – 6/18/2023)
· No Oral Modification
· Representations Re: Corporate Licensees

The Licensees/Respondents/Representatives stated they would abide by the following:
· Abide by the contents/terms of the Stipulation
· Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted with Regional Vice-President Sonya Buchanan, Vice President of Clinical Services Kandice Alcorn, RN MSN, and Executive Director Dale Masters 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: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020

LIC809 (FAS) - (06/04)

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