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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 07/14/2021
Date Signed: 07/14/2021 04:36:49 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 ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:DONNA BAUTISTA-COLMENARESFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 51DATE:
07/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
04:45 PM
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Prior to arrival at facility Licensing Program Analyst (LPA) Victoria Brown asked the Business Office Manager the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and Diarrhea. Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a "No" answer to all of the above questions.


Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 7/14/21 at 12:50PM. LPA met with Executive Director/Administrator Donna Bautista-Colmenares and stated the purpose of the visit. LPA attempted to conduct interviews regarding incident reports received indicating medication errors had occurred on several dates. The dates were as follows: 7/14/2020, 8/25/2020, 9/25/2020, 9/26/2020, and 5/26/2021. Additional documentation was requested from the Administrator such as LIC602, training confirmation for staff, Charting Notes, and medication documentation.

Occurrences Need Further Investigation.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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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