347005239-11-1-2021-27-AS-KHOS-C8LLNP-20211109075440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 11/01/2021
Date Signed: 11/01/2021 05:12:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20211029101055

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DONNA BAUTISTA-COLMENARES		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 54	DATE:	11/01/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility staff are not wearing masks.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown and Licensing Program Manager Stephen Richardson arrived unannounced to conduct a complaint investigation of the above mentioned allegation on 11/1/21 at 10:30am. 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. The team reviewed documents, Facebook video and photos with Administrator. Interviews of Staff #1 (S1)- (S5) were conducted during this visit.

Regarding the allegation, “Facility staff are not wearing masks”, the investigation revealed that the facility staff were inside the facility taking multiple photos while not social distancing and S1 was not wearing a mask. The video posted on the facilities Facebook website was shown to S1 and the Administrator who confirmed the identity of S1. S1 stated the photos were taken in the common area of the building.

Substantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211029101055

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 Department disseminated a Provider Information Notice (PIN) 21-38-ASC which states on page 3 that ...masks are required for all individuals regardless of their vaccination status.

Based on interviews, video and photos, the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D 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. An exit interview was conducted with Donna Bautista-Colmenares and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211029101055

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HSC 1569.58(a)(2	1 2 3 4 5 6 7	... any employee, prospective employee, or person who is not a client and who has done any of the following: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.	1 2 3 4 5 6 7	Licensee/Administrator shall submit a plan by 11/2/21 on when an all staff training will be conducted for Infection Control/Mitigation Plan, the most recent (PIN), staff to give reminders to memory care residents, as well as sanitizer use by staff regarding infection control and/or masking guidance.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: S1 was not wearing a mask in the facility while posing for pictures and not social distancing from other staff. Based on S1 confirmed as one of the infection control leads did not follow the infection control practices in their Mitigation Plan dated 5/10/21 effectively putting residents at risk. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14	The training documentation is to include Title of training with details/date/time/length of training/name of trainer/participants names and signatures. The training shall be completed with proof of attendance by 11/8/21 via fax.
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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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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