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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 08/19/2021
Date Signed: 08/19/2021 02:34:43 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: 53DATE:
08/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent complaint visit on 8/19/2021 at 2:00pm. LPA was met by Donna Bautista-Colmenares, Administrator and stated the purpose of the visit. This visit is to cite deficiencies observed while conducting the complaint investigation and a file review.
CCL requested a copy of R1’s Admission Agreement on three different dates June 15, 2021, June 22, 2021, and July 2, 2021. Administrator failed to provide the requested Admission Agreement that was needed to further investigate the complaint.
The findings observed were that the staff removed the wheels of the chairs in R1’s room after a fall in April during which time there were at least 3 falls noted on R1’s Interim Service Plan.
In addition, LPA did not receive a request to remove the wheels from the chairs with supporting documentation as to the reason nor any documentation from the physician indicating it was necessary for the safety of the resident. This violates the resident’s rights.
An interview on 12/8/2020 with S1, Med Tech revealed that R1 was a fall risk indicated by a wristband that R1 wore. The facility did not document that R1 was checked every 1-2 hrs. The Charting Notes indicate that R1 was checked sometimes once a day or two to three times a day.
The preponderance of evidence standards has been met.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held with Administrator. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited

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Admission Agreements
The admission agreement shall be reviewed at the time of the compliance visit and in response to a complaint involving the admission agreement.

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This requirement is not met as evidenced by: CCL requested the Admission Agreement 3 times during the course of the investigation
Based on Observation, CCL did not receive the Admission agreement to include in the investigation
This poses an immediate health and safety risk to residents in care.

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Type A
08/20/2021
Section Cited

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Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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This requirement is not met as evidenced by: Licensee removed the wheels from resident’s chair
Based on interviews the wheels were removed from the chairs in residents’ room after a fall
This poses an immediate health and safety risk to residents in care.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021
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: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited

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Program Flexibility
The use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: Such alternatives shall be carried out with provisions for safe and adequate services.
A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee.
Prior written approval of the licensing agency shall be received. In determining the merits of each request, the licensing agency shall use as guidelines the standards utilized or recommended by well-recognized state and national organizations as appropriate. The licensing agency shall provide written approval or denial.
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This requirement is not met as evidenced by: Facility did not submit an Exception request to CCL for approval to remove the wheels from residents’ chairs
Based on interviews the wheels were removed from the chairs in residents’ room after a fall which was done without approval from CCL
This poses an immediate health and safety risk to residents in care.
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Type A
08/20/2021
Section Cited

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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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This requirement is not met as evidenced by: Facility did not ensure resident was checked as stated in the ISP. The ISP stated that R1 can be forgetful and confused, needs to assistance with re-orienting, reminding, and activities of daily living (ADL) to be checked every 1-2 hours.
Based on a review of the Facility Charting Notes R1 was not checked every 1-2 hours
This poses an immediate health and safety risk to residents in care.

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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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