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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 01/12/2022
Date Signed: 01/12/2022 03:18:17 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:CHRISTINA L. GARCIAFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 46DATE:
01/12/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christina Luna GarciaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Victoria Brown and Jamie Ivey Canady arrived unannounced to conduct a Case Management visit on 1/12/22 at 9am. LPAs was met by Christina Luna Garcia, Administrator and Brian Pawloski, Vice President and stated the purpose of the visit. The Administrator certificate expires 8/12/2023 for Christina Luna Garcia. There are 2 residents receiving hospice care services at this time. LPAs observed the (LIC308) Designation of Responsibility posted.

LPAs toured the physical plant of Assisted Living and Memory Care sides and kitchen area. Currently there are 15 staff working during this visit. LPAs observed a random amount of rooms which contained the required furniture and lighting. LPAs observed the first aid kit to contain the required items.

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

LPAs observed 2 day perishable and 7 day non-perishable food supplies. The room temperature in the facility was logged on the wall thermostats at 75*F. The water temperature in a random amount of rooms measured between 106.9 - 115.3*F.

LPAs observed staff conducting activities of daily living with residents while others engage in individual activities.

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, Administrator and 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: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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