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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:46:44 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: 54DATE:
10/22/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a health and safety check on the residents and observe the procedures put in place according to the Health Care Associated Infections (HAI) visit on 10/13/21. LPA met with Staff #1 (S1) and stated the purpose of the visit. LPA toured the physical plant inside and outside. At 9:00am S2 arrived and Donna Baustista-Colmenares, Administrator arrived at approximately 10:30am to assist with todays visit.

LPA observed the medication rooms for both the assisted living and memory care areas. LPA observed the required items for the first aid kit with the assistance from S3. LPA observed the red zone area.
LPA requested to review medications with S1. LPA and S1 found discrepancies in the process used for the medication room. LPA observed that the pill container and container slot for resident #1 (R1) had two different room numbers. LPA was informed R1 moved to a different room 1 month ago and the cup has not been changed. LPA observed cups for R2, and R3 did not have a name on it. In addition, R2's cup was turned to the side containing pills, no lid with a small paper cup on top of the pills. LPA observed R4 received a medication of Amlodipine 10mg Tab at 8am and upon review of the QuickMar, staff was unable to explain the system of using the bubble pack as there were 6 pills missing from the bubble pack and the MAR showed 15 administered for the month of October, 2021.
LPA did not observe a posting and staff had no knowledge of the (LIC308) Designation of Responsibility form. This was discussed during a telephone call on 9/16/21 with Administrator Donna Bautista-Colmenares, Licensing Program Manager Stephen Richardson and LPA. The conversation was also discussed with Brian Pawloski as well on a separate call the same day.
During a meeting on 10/19/21, Administrator stated a smoking area sign will be posted as well as hand sanitizer for resident use. LPA did not observe signs or hand sanitizer in the area during this visit. This will be mentioned on a Technical Assistance (LIC9102) during this visit.

LPA took photos of the areas of the facility mentioned above during this visit.

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: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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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: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited

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Administrator - Qualifications and Duties
All facilities shall...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...
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This requirement is not met as evidenced by: During the CM visit there was no LIC 308 designating anyone
Based on Facility staff did not have knowledge of the LIC 308.
This posed a potential health and safety risk to residents in care.
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Type B
10/25/2021
Section Cited

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Personnel Requirements - General
All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:Knowledge required to safely assist with prescribed medications which are self-administered.
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This requirement is not met as evidenced by: During the CM visit the staff and LPA observed discrepancies in the medication room.
Based on Facility staff and LPA found pill container/container slot for R1 had two different room numbers, 2 cups did not have a name on it, 1 cup did not have a lid with pills inside with a small paper cup on top of the pills, staff was unable to explain the system of using the bubble pack.
This posed a potential 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: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
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