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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 03:30:09 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 - OtherUNANNOUNCEDTIME 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 purpose of the visit is to review additional items that were observed during the complaint investigation on 12/3/21. LPAs requested a copy of the physician report for resident #1 (R1).

During the course of the investigation, LPA observed that R1 was sent out to the hospital to pick up insulin by way of an Uber. R1 was also brought back to the facility by an Uber with a different type of insulin which was in vial form not the usual pen form. It was revealed that initially the resident was sent to the wrong VA hospital to pick up the medication. R1 informed the driver that they were going the wrong way and the Uber driver took R1 to the correct address.
On 11/23/21, the previous administrator Donna Bautista-Colmenares stated that R1 was sent out for an appointment and to pick up the insulin. A review of the physician report dated 6/18/2021 revealed that R1 was deemed not able to leave the facility unassisted.

Based on interviews, and documentation the preponderance of evidence standards has been met. R1 was sent out to pick up medication without supervision.

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. An exit interview was conducted, a copy of the report was given.
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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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: 01/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2022
Section Cited

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Administrator - Qualifications and Duties
The administrator shall have the responsibility to: Develop an administrative plan and procedures to ensure clear definition...and adequate supervision.
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This regulation was not met as evidence by: The licensee did not provide R1 supervision. Based on information provided through documentation and interviews, Administrator did not provide supervision for R1 while being sent to the VA hospital in an Uber.
This poses an immediate 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: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022
LIC809 (FAS) - (06/04)
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