347005239-2-24-2021-27-AS-VBRN-BYK337-20210224165303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 02/24/2021
Date Signed: 02/24/2021 04:54:12 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:	DONNA BAUTISTA-COLMENARES		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 44	DATE:	02/24/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	05:00 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 unannounced Tele-visit on 2/24/2020 at 3:00pm due to COVID-19 and pre-cautionary measures. LPA met with Donna Bautista-Colmenares and Luna Garcia, Business Office Manager and discussed the purpose of the call and the elements of this type of visit. This visit is to ensure that the care home is meeting the terms and conditions of its probationary license effective 6/18/2020 to 6/18/2023. LPA was allowed entry into the facility. Administrator certificate expires on 9/18/2022. LPA observed, assessed and communicated with a random amount of residents present during this visit. LPA, Donna Bautista-Colmenares, and Eric Guererro the Maintenance staff toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed the storage areas, bedrooms and bathrooms, required furniture and lighting during this visit. LPA observed equipment such as stove, and refrigerator (s) to be operable and knives were inaccessible during this visit. The temperature inside the facility was measured at 72F on the thermostat on the wall of the facility which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 114.2F in room 119 and 116.2*F in room 126 which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed oxygen signs posted for those who are using oxygen and the tanks are secured during this visit. LPA observed the 7 day non-perishables and 2 day perishables on site.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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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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: 02/24/2021

NARRATIVE

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The medications were found locked and inaccessible. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution.

At 3:45pm, LPA observed 1 resident file and 1 staff file which was found to contain the required items.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited.
An exit interview was conducted with Donna Bautista-Colmenares via telephone and a copy of this report was provided to Donna Bautista-Colmenares via email.

An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC809 (FAS) - (06/04)

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