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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 11/16/2022
Date Signed: 12/13/2022 11:30:43 AM

Substantiated


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
06/02/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20220602111746
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: 52DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kayla DavisTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by administrator Kayla Davis.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of LPA facility observations, interviews with staff, interviews with residents and review of resident files, resident medical files, and chart notes.

The Department has determined the following as it relates to the allegations: Resident sustained pressure injury while in care.
Continued on LIC 9099 - C...
This document has been amended to remove additional allegations which are listed on 9099A
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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 7
Control Number 27-AS-20220602111746
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: 11/16/2022
NARRATIVE
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On 8/23/2022, 10/24/2022, 10/31/2022 and 11/02/2022 LPA Ivey Canady visited the facility and conducted interviews with staff, interviews with residents and documentation reviews that included chart notes and medical files. According to medical file reviews, chart note reviews and physician order reports, as well as staff interviews, Resident 1 (R1), R6 and R5 sustained a pressure injury while in care. In regard to R6, and according to interviews with staff, hospice was notified of R6 having the beginnings of a pressure injury and an appropriate medical device was put into place to address the pressure injury before it advanced. Based on interviews with 3 out of 7 staff, R5 did sustain a pressure injury while in care of the facility. During review of medical files, LPA did discover R1 had sustained a pressure injury that advanced to level 3. Therefore, the allegation: Resident sustained pressure injury while in care is Substantiated. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20220602111746
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: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1)Prohibited Health Conditions(a)Persons who require health services for or have a health condition including, but not limited to....(1)Stage 3 and 4 pressure injuries. This regulation was not met as evidenced by:

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Licensee stated the facility will host an all staff meeting regarding resident change in condition and also a transfer training and facility will review with staff Title 22 Regulation for restricted Health Conditions and provide LPA with sign in sheets and training documents by 11/17/2022.
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Based on interviews with facility staff, home health company staff, resident medical file reviews and interviews with residents, licensee did not ensure R1, R5 and R6 did not sustain a pressure injury while in care. This poses a health and safety 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: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
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
06/02/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20220602111746

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: 52DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kayla DavisTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident not administered medication as prescribed.
Staff forced resident to get out of bed.
Residents diabetic care needs are not being met.
Resident is not being rotated and repositioned.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by administrator Kayla Davis.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of LPA facility observations, interviews with staff, interviews with residents and review of resident files, resident medical files, and chart notes.

The Department has determined the following as it relates to the allegations: Resident sustained pressure injury while in care. Resident not administered medication as prescribed. Staff forced resident to get out of bed. Residents diabetic care needs are not being met. Resident is not being rotated and repositioned.\

Continued on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220602111746
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: 11/16/2022
NARRATIVE
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On 10/24/2022 and 10/31/2022 LPA conducted interviews with facility staff that assist with the administration of diabetic medications. LPA checked staff credentials with facility administrator to verify each staff that assist with the administration of diabetic medications are licensed to do so. LPA also conducted interviews with staff that are not licensed to administer diabetic medications to decipher and ensure no unlicensed staff are assisting with the administration of diabetic medications. Based on LPA investigation, no unlicensed staff are assisting with the administration of diabetic medications. On 10/31/2022 LPA requested facility LVN explain in detail the process of determining the proper dosages for diabetic medication and also provide medical files and charts where diabetic medication had been administered based on glucose findings and medication type. On 10/31/2022 LPA reviewed facility Blood Glucose Administration computer software which demonstrated a detailed daily accounting of all blood glucose checks and medications administered by licensed facility personnel. Based on LPA access to view facility charted database, interviews with residents, interviews with current facility , review of facility medical files and chart notes, all medications are administered as prescribed. Therefore, regarding the allegation: Resident not administered medication as prescribed is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
On 10/31/2022 LPA conducted interviews with facility staff, and facility residents regarding the allegation Staff forced resident to get out of bed. Based on interviews with 6 out of 6 residents, no resident was forced to get out of bed against the will of the resident. Based on interviews with staff and residents, and review of facility chart notes, LPA did not discover any evidence that substantiated the allegation of a resident being forced get out of bed against the residents will.

Cont 9099-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220602111746
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: 11/16/2022
NARRATIVE
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Therefore, regarding the allegation Staff forced resident to get out of bed is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
On 10/31/2022 LPA Ivey Canady reviewed resident files and Physician Reports (LIC602) of residents that are administered diabetic medications. According to interviews with residents, residents are pleased with the care that is being received. 3 out of 4 diabetic residents stated all diabetes insulin numbers are checked daily and reports the staff are doing a good job during finger poke checks. 1 out of 4 diabetic residents stated all diabetic care at the facility is self-care with the occasional assistance of finger poke. All residents are receiving diabetic medications as prescribed and any assistance provided is provided with the assistance of a licensed professional. LPA reviewed facility chart computer system application that provides a detailed tracking system which includes all pertinent data, including glucose numbers, insulin and all subsequent insulin and pill dosages administered. Therefore, the allegation of Resident diabetic care needs are not met is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
According to interviews with facility staff and record review, any resident that has required repositioning and rotation is under the care of hospice. Facility administrator explained that hospice provides the facility with an order to rotate and reposition said residents based on the resident care needs. Onn 10/31/2022, LPA requested and received hospice notes and copies of orders for hospice residents that require rotation. According to chart notes, hospice orders and medical reviews all residents requiring rotation and repositioning are receiving those services as ordered and charted with date stamps that have been observed by LPA.
Cont 9099-C
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20220602111746
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: 11/16/2022
NARRATIVE
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 Therefore, the allegation resident is not being rotated and repositioned is Unsubstantiated. An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7