347005239-7-21-2021-27-AS-SRIN-C57VFQ-20210723162419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:40:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210315134020

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: 53	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident admitted to Hospital with opiate overdose.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Prior to arrival at facility Licensing Program Analyst (LPA) Victoria Brown asked the staff 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.

Substantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20210315134020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/21/2021

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
26
27
28
29
30
31
32

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a follow-up to the complaint investigation to amend the findings from UNFOUNDED to SUBSTANTIATED on 7/21/21 at 9:30AM. LPA met with Executive Director/Administrator Donna Bautista-Colmenares and stated the purpose of the visit.

Upon further review of documentation and interviews, it is determined that the allegation,"Resident admitted to Hospital with opiate overdose" will be cited during this visit. The Incident Report and SOC341 dated 3/15/21 and interviews conducted on 7/14/21 revealed that R1 went to the hospital for a diagnosis of overdose on 3/12/21. During which time the Administrator acknowledge the source that was providing drugs to the resident. On 5/5/21, an incident report was submitted indicating the source delivered drugs again to the facility for the resident. Administrator stated that a plan was put in place to search the deliveries prior to resident obtaining them. During interviews, LPA obtained information that the bag was initially given to the front desk staff then to the caregiver to deliver to the resident at which time the caregiver heard a sound in the bag. Upon a search of the bag the drugs were observed to be inside other food product packaging, the caregiver notified the Administrator. Although the drugs were confiscated, the facility did not follow their protocols effectively to ensure the residents safety while in care.
In addition, LPA observed 3 Incident Reports submitted by the facility regarding over-medication errors. On 7/14/2020, R2 received the same medication twice for the day. On 8/25/2020, R3 received the same medication twice for the day. On 5/26/2021, R4 received the incorrect medication.
All documentation and interviews shows that the facility has had a history of overdosing the residents from 2020 to date.
Based on observation, interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D 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. An exit interview was conducted, the report was read to Donna who had an appointment and requested Luna Garcia, BOM sign it and a copy of the report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210315134020

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 08/21/2021 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Licensee/Administrator shall submit a plan by POC due date on training for Med Tech and Nurses on Medication Procedures and Personal Rights for Residents. The plan is to include some form of tracking/documentation. The training shall be completed with proof of attendance through signatures of staff by 8/6/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Drugs were delivered to R1 despite plan in place by facility and R2-R4 received additional medications above what was prescribed Based on Facility did not follow plan effectively that they put in place for R1 and did not ensure R2-R4 receive medication as prescribed This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3