347005239-3-27-2021-27-AS-KHOS-BZNLDN-20210401084012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 03/27/2021
Date Signed: 03/27/2021 04:49:28 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
06/15/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200615110930

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DALE MASTERS		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 46	DATE:	03/27/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff handled resident in a rough manner causing bruises

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown contacted the facility via telephone to commence an unannounced Tele-visit on 3/27/2021 at 4:30pm due to COVID-19 and pre-cautionary measures. LPA met with Donna Bautista-Colmenares and discussed the purpose of the call and the elements of this type of visit.

On 6/15/2020, Community Care Licensing (CCL) received a complaint regarding the allegation of “Staff handled resident in a rough manner causing bruises”. On 6/18/2020, LPA conducted an initial 10-day visit, met with Luna Garcia, Business Office Manager and Dale Masters, Executive Director. LPA requested and received a copy of the staff roster with contact information, a resident roster and a medication list for Resident #1 (R1). LPA received a copy of those documents along with a photo of R1's wrist, and statements from staff.

The investigation revealed that S1, S2, and S4 confirmed yelling between R1 and S13.
S1 and S3 confirmed that R1’s wrists were grabbed and S3 and S5 witnessed the bruises.

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20200615110930

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: 03/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To be free from…abuse, or other actions of a punitive nature…	1 2 3 4 5 6 7	Licensee has suspended and terminated the employment of S13. POC cleared prior to todays visit.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: R1 having bruises on the wrist. Based on interviews, the licensee did not ensure S13 kept resident free from abuse or other action of a punitive nature. This posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 03/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20200615110930

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: 03/27/2021

NARRATIVE

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During an interview on 3/27/21, S13, confirmed that there was yelling and R1’s wrists were grabbed and was not sure if bruises were left.

The preponderance of evidence standards has been met. The allegation is SUBSTANTIATED.

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. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted with Donna Bautista-Colmenares via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021

LIC9099 (FAS) - (06/04)

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