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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 11/01/2021
Date Signed: 11/01/2021 05:07:33 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:
11/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced on a subsequent complaint investigation 27-AS-20211029101055 at 10:30am on 11/1/21. The team met with Donna Baustista-Colmenares, Administrator and stated the purpose of the visit.

The team toured the physical plant inside to ensure there are no health and safety concerns. LPA and LPM interviewed staff and administrator during this visit.

The team reviewed documents, Facebook video and photos with Administrator. Interviews of Staff #1 (S1) - (S5) were conducted during this visit. LPA requested a copy of the Photo Use Release Form for each resident in the video and photos. LPA observed 1 (R3) out of 3 residents agreed to the release which was dated 3/16/21.

LPA and LPM interviewed Administrator to confirm individuals in the video from the facilities Facebook website and photos. The administrator stated R4 was in the video with R2 and R3. Administrator introduced the team to R4 and assured the team the person was R4. Upon further interviews, LPA and LPM discovered the resident in the video was in fact R1.

The investigation revealed that the facility has not obtained permission to publish and/or release Resident #1 (R1) and R2's photo.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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
VISIT DATE: 11/01/2021
NARRATIVE
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The investigation also revealed that the Administrator did not submit an incident report of hospitalization for R5 timely nor was R5 included on the required Public Health line list for covid positive persons. R5 went to the hospital on 9/28/21 and the document was submitted by fax 10/21/21. According to the Administrator the fax was not working properly.

Based on the information received through interviews, a deficiency for false claim, information release, reporting requirements will be cited during this case management visit. LPA and Administrator reviewed the residents release form together 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 Donna Baustista-Colmenares, 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: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...any; and disposition of the case.
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This requirement is not met as evidenced by: Administrator submitted hospitalization incident 23 days later. Based on Administrator did not submit Incident report timely. This violation poses an immediate health, and safety risk to residents in care.
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Type A
11/02/2021
Section Cited

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement is not met as evidenced by: Administrator had knowledge of R5 being covid positive. Based on Administrator provided line list that did not include resident as covid positive to Public Health or CCL.
This violation poses 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: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 11/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2021
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities
In addition to the rights listed in Section 87468.1, ...residents ...shall have all of the following personal rights:To have ...personal information remain confidential and to approve their release, except as authorized by law.
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This requirement is not met as evidenced by: Administrator provided to CCL resident records for residents in Facebook video. Based on Administrator did not have permission to release residents R1 and R2 in video on social media (Facebook).
This violation poses an immediate health, and safety risk to residents in care.
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Type A
11/02/2021
Section Cited

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False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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This requirement is not met as evidenced by: Administrator stated that R4 was in the Facebook video. Based on Administrator did not give the true identity of R1 during an investigation.
This violation poses 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: 11/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4