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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:25:22 PM


Document Has Been Signed on 08/23/2022 01:25 PM - It Cannot Be Edited

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:MALISSA ACUNAFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 54DATE:
08/23/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Malissa AcunaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a health and safety visit. LPA met with administrator/ executive director Malissa Acuna, and explained the purpose of the visit.

LPA interviewed 2 staff. LPA Valerio observed 5 bedroom and bathrooms. LPA observed 4 out of 5 rooms to be clean and free of debris. Resident 1's (R1) room was observed. LPA observed the bathroom shower, which had black mold along the floor ground and corners of the tile. Staff stated that the resident does not use the shower and receives bed baths. Staff state that housekeepers are in charge of the room cleaning; however, if caregivers observe plates or the room not being clean, they will clean it. LPA observed facility files. R1's file showed that family requested to have housekeeping services removed. R1's family would be the one to manage the housekeeping in the room. Although there is an agreement between the family and the facility, the facility is still required to have bathrooms maintain in a clean, sanitary, and odorless condition.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited and can be found on the LIC 809-D. Failure to correct these deficiencies may result in civil penalties. Exit interview held with Administrator Malissa, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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Document Has Been Signed on 08/24/2022 08:57 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/24/2022 08:55 AM

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: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by:
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Based on observations, the licensee did not ensure 1 out of 5 resident bathrooms to be maintained in a clean and sanitiary condition. Resident 1 bathroom was observed to have mold along the floor tiles, which poses a potential health and safety risk to residents in care.
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This report was amended to reflect correct POC due date.

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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: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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