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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 11/12/2021
Date Signed: 11/12/2021 04:37:56 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: 52DATE:
11/12/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Donna Bautista-ColmenaresTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/12/21 at 2:00pm to conduct a Case Management visit. LPA was met by Donna Bautista-Colmenares, Administrator and stated the purpose of the visit.

LPA arrived during shift change, currently there are 3 caregivers and 1 medication technician on each side of the building.

LPA toured the physical plant of Assisted Living and Memory Care sides and kitchen area.

LPA observed the first aid kit to contain the required items.

LPA observed the fire extinguishers to be in compliance. The facility has a pull alarm system that is hard wired with the smoke detectors. LPA also observed carbon monoxide detectors present in facility.

LPA observed 2 day perishable and 7 day non-perishable food supplies. Per administrator additional items will be delivered on 11/13/21.

LPA observed staff in memory care conducting activities and on the assisted living side there is individual activities being conducted.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held with Christina Garcia as Administrator was assisting families during this exit interview. 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: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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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