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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:37:03 AM


Document Has Been Signed on 10/06/2022 11:37 AM - 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: 53DATE:
10/06/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Malissa AcunaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 10/6/22 at 9:00am on a subsequent visit. LPA was met by Malissa Acuna, Administrator and stated the purpose of the visit. The facility is licensed for a capacity of 105. The Administrator certificate expires 2/16/23.

LPA observed 2-day perishables and 7-day non-perishables.

There are 9 residents receiving hospice care services at this time. LPA toured the physical plant of Assisted Living (AL) and Memory Care (MC) sides and kitchen area. Currently there are 5 Caregivers in AL with 1 med tech and 1 LVN and 6 caregivers in MC and 1 med tech and 1 LVN on the floor working during this visit.

LPA observed a random amount of rooms which contained the required furniture and lighting.

Residents were preparing for lunch which included hamburger casserole, parsley carrots, dill pickle pasta salad, garden vegetable soup, blonde brownie, and cranberry juice, tea, coffee, and water.

The temperature inside the facility was observed to be 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.5*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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