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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 08/16/2021
Date Signed: 08/16/2021 05:29:28 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:
08/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 8/16/21 at 1pm. LPA met with Donna Bautista-Colmenares and stated the purpose of the visit.

Community Care Licensing (CCL) received an Incident Report indicating that on 9/26/21 at 6am Staff #1 (S1) and (S2) noticed a bubble pack of Hydrocodone had 4 tabs missing and replaced with unknown pills possibly Tylenol.

At 2pm, S1 and S3 noticed a different bubble pack of 1/2 tabs of Hydrocodone one was replaced with unknown pills possibly Tylenol and taped.

The Administrator was notified of the tampering. Staff #1 (S1), (S2), and (S4) were drug tested and results were negative. S3 failed to appear for 2 work shifts and termination was in process. An LVN had been hired to replace the Medication Technician (Med Tech) and the other 2 med techs were removed from medication duty. The Administrator stated that no other residents who use Tylenol medications were missing. However, during a medication count on 9/25/2020 these errors were not found.

Based on observation, interview, and documentation the preponderance of evidence standards has not 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. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited

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Personnel - Operations
In each facility:Care and supervision of residents shall be provided without...exploitation...The licensee shall provide for and encourage all personnel to report observations or evidence of such ...exploitation...
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This requirement is not met as evidenced by: Staff found that resident(s) medication(s) were missing.
Based on MAR review with Administrator Licensee did not ensure resident(s) were not exploited by removing prescribed medication for med room.
This posed an immediate health and safety risk to residents in care.
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Type A
08/17/2021
Section Cited

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Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained ...control and custody of the medication.
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This requirement is not met as evidenced by: Staff replaced prescribed medication with unknown medication.
Based on MAR review with Administrator Licensee did not ensure prescribed medication(s) were centrally stored safely
This posed 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: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021
LIC809 (FAS) - (06/04)
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