347005239-12-3-2021-27-AS-SRIN-C9ZT9J-20211224133202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 12/03/2021
Date Signed: 12/03/2021 04:50:11 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
11/17/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20211117084151

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: 52	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Resident missed medications
Illegal eviction due to resident not providing 30 day supply of medication prior to admittance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/3/21 at 1:35pm to conclude the investigation the above-mentioned allegation(s). LPA met with Donna Baustista-Colmenares, Administrator and stated the purpose of the visit.

Regarding allegation, "Resident missed medications", the investigation revealed that resident #1 (R1) was informed there was no medication (insulin) for the next dose. R1 was sent out to the pharmacy to pickup the insulin. R1 arrived back to the facility with vials without syringes. The facility staff informed R1 that there were syringes in the facility already from their pharmacy. R1 was informed that the staff found the remaining insulin in one of the refrigerators. The administrator stated that R1 missed a dose that night and a prescription for the syringes is not necessary for the vials although R1 used Kwik Pens since admittance that has a prescription for the syringes. The Administrator stated that the medication was found in one of the refrigerators the next day which was an oversight. The Administrator also stated the they didnt just send R1 out for the insulin because R1 had a scheduled appointment that day.

Substantiated

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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-20211117084151

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: 12/03/2021

NARRATIVE

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Regarding allegation, "Illegal eviction due to resident not providing 30 day supply of medication prior to admittance", the investigation revealed that R1 was admitted to the facility on 6/30/21 with belongings and assigned a room. The facility staff stated that R1 had to leave the facility because R1 did not have a 30 day supply of medications on hand. Administrator stated she did not recall or probably is the one who called the family to pick up R1, however, when a resident moves in they must have a 2 week to 30 day supply of medications. Administrator stated that the resident was only in the facility for a couple of hours and must leave the building. Staff concurred that Administrator stated R1 had to leave the building on that same day. Administrator and staff were not sure where R1 was relocated for 2 days with belongings still in the facility.
A review of the Plan of Operation, Admission Agreement, and Interviews of staff and Administrator did not reveal any documentation that required a 2 week or 30 day supply on medications on hand upon admittance.

Based on interviews, and documentation 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, a copy of the report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211117084151

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: 12/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/04/2021 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)...	1 2 3 4 5 6 7	Administrator shall submit a letter of understanding that a review of the Plan of Operation, Admission Agreements, and Title 22 Regulations shall be conducted prior to any evictions along with a copy of the written notice submitted to CCL. POC due by due date faxed to (916) 263-4744.
	8 9 10 11 12 13 14	This regulation was not met as evidence by: The licensee did not provide R1 an eviction notice. Based on information provided through documentation and interviews, Administrator evicted R1 for not having a 30 day supply of medication upon admittance. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14
Type A 12/04/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed...The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Based on documentation of trainings received by staff regarding medication, the amount of medication errors cited, and the Stipulation and Waiver; and Order that was issued to the facility on 6/18/2020, the facility shall locate an outside Vendor to conduct training to all employees who administer medication to clients on
	8 9 10 11 12 13 14	This regulation was not met as evidence by: The licensee did not provide R1 with required refrigerated medication timely. Based on information provided through interviews, Administrator admitted that R1 missed a dose of insulin that was found the next day. This poses an immediate risk to residents in care.	8 9 10 11 12 13 14	Medication Management this training shall include the Administrator. The plan to be submitted by 12/4/21 and the Vendor name and dates of trainings shall be submitted to CCL by due 12/8/21 faxed to (916) 263-4744.

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: 12/03/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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