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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 09/22/2021
Date Signed: 09/22/2021 04:21:39 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: 55DATE:
09/22/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/22/21 at 1:30pm on a subsequent Case Management visit. LPA was met by Donna Bautista-Colmenares, Administrator and stated the purpose of the visit. This visit is to review a random amount of resident files.

LPA requested a copy of the resident roster. LPA requested to review a random amount of residents annual assessment or physician report. LPA received a copy of the 7 Physician Reports.

LPA observed 6 residents Physician Report (LIC602) of residents who are currently residing in the facility.

LPA also observed 1 resident Physician Report who moved out of the facility.

LPA observed that 6 of the LIC602s have been updated within the year of 2021 except 1 for the resident who left the community on 8/6/2020 prior to the LIC602 annual due date of 8/27/2020.


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, No deficiencies are being cited during this visit. 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: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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