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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:17:55 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: DATE:
10/19/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
10:15 AM
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An Office Meeting was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this meeting is to discuss the recommendations from the Health Care Associated Infections (HAI) in order for the facility to remain in substantial compliance with infection control. Present in the meeting is Regional Manager Krystall Moore, Licensing Program Manager Stephen Richardson, Licensing Program Analyst Victoria Brown and representatives of FC Ranger OPS Greenhaven Estates; GH Senior Living: Administrator Donna Bautista-Colmenares, Vice President of Clinical Services Kandice Alcorn, Vice President of Operations Northern California Brian Pawloski, Environmental Service Director Eric Guerrero, and Resident Care Coordinator Brittany Ram. The purpose of the meeting was explained which is to mitigate the spread of Covid-19.

There was a joint Health and Safety visit to the facility on 10/13/21 with Health Care Associated Infections (HAI) representative Kristy Trausche, Infection Preventionist, California Department Public Health (CDPH)
The team CCL, CDPH, RCC, and Administrator conducted a physical plant tour of the facility reviewing processes set in place.

Todays meeting recapped recommendations set forth from CDPH's Covid-19 Outbreak Facility Assessment Tool and to review how the facility is implementing these recommendations. The (LIC808) Mitigation Plan submitted to CCL states that RCC, Brittany Ram and ESD Eric Guerrero are the Infection Control Leads of the facility and updates are to be maintained. The Administrator has agreed to submit an updated line list to Community Care Licensing (CCL) and Public Health on a daily basis.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Donna Bautista-Colmenares via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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