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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 11/16/2022
Date Signed: 12/19/2022 02:37:55 PM

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
06/01/2022 and conducted by Evaluator Jamie Ivey-Canady
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220601155859
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 has unknown wound on back open
Facility is retaining a resident beyond their level of care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s 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, residents and review of resident files.

The Department has determined the following as it relates to the allegations: Facility is retaining a resident beyond their level of care. Resident has unknown wound on his back opened.
: Continued on LIC 9099 - C...

This document has been amended to remove additional allegations which are listed on 9099-A
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 6
Control Number 27-AS-20220601155859
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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During facility visit on 10/31/2022, LPA interviewed R1 regarding reported wound. R1 reports there is no wound on the back and never has been. According to resident medical review, there is a reported medical condition of R1 having a wound that progressed to a stage 3 pressure injury in the Coccyx area. LPA observed R1 to be overall generally healthy and in command of faculties. On 11/10/2022 LPA interviewed staff with the Home Health Care Plan that provided services to R1 during 05/29/2022 at the facility. According to witness statements and medical record review to include physicians order report, R1 did sustain a pressure injury in the Coccyx area that is identified by witness statement as on the backside, that progressed to stage 3 while in the facility, therefore, the allegation Resident has unknown wound on back opened 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.
On 10/31/2022, 10/24/2022 and 8/23/2022 LPA reviewed chart notes, medical records, and physician order reports for R1. On 7/19/2022 LPA interviewed witness regarding pressure injury on the back of R1. On 11/10/2022 LPA requested and received additional medical record documentation concerning alleged stage 3 pressure injury. Information contained in the medical record included stage level of pressure injury as well as dimensions. According to witness statement, review of medical records, home health care chart notes and physician order report, R1 did sustain a pressure injury that advanced to stage level 3. Based on facility Plan of Operation regarding services provided, and the scope of services the facility is licensed to provide, R1’s pressure injury condition did advance outside the scope of services the facility is licensed to provide for a period of 1 month. Therefore, the allegation of, Facility is retaining a resident beyond their level of 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), both allegations 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: 2 of 6
Control Number 27-AS-20220601155859
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 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including...(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 information provided, review of resident medical files, and interviews with residents and interviews with staff; licensee did not ensure R1 pressure injury did not advance to stage 3. This posed an immediate health and safety risk to persons in care.
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Type A
11/16/2022
Section Cited
CCR
87468.2(a)(4
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs... This regulation was not met as evidenced by:

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Licensee stated the facility will review resident LIC602 and care plans to ensure proper level of care and compliance. Licensee will provide LPA with a statement of completion by COB 11/17/2022.
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Based on information provided, review of resident medical files and interviews with residents and staff; licensee did not ensure not to retain a resident beyond the facility level of 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: 3 of 6
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
06/01/2022 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20220601155859

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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Facility admitted a resident that is outside the scope of care for the facility.
Resident has to be fed all meals.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)s 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, residents and review of resident files.

The Department has determined the following as it relates to the allegations: Facility admitted a resident that is outside the scope of care for the facility. Resident must be fed all meals.
: Continued on LIC 9099 - C...

This document has been amended to remove additonal allegations that are listed on the original 9099.
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: 4 of 6
Control Number 27-AS-20220601155859
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 11/03/2022, 10/31/2022, 10/24/2022 and 8/23/2022 LPA Ivey Canady interviewed facility Staff regarding allegation “Facility admitted a resident that is outside the scope of care”. LPA requested and reviewed facility Plan Of Operation and Admission Agreements for R1, R2, R3 and R4. All agreements are in alignment with services offered by the facility in accordance with the facility Plan of Operation. Based on LPA investigation and review of facility documents to include LIC602s for R1, R2, R3 and R4 and chart notes for R1, R2 and R3, all current residents are within the scope of the facility. According to interviews with 8 out of 8 residents, residents are pleased with the care that is being received. 8 out of 8 residents state needs are being met. Based on 4 out of 4 residents in diabetic care, 3 out of 4 stated all diabetes insulin numbers are checked daily and reports the staff are doing a good job during finger poke checks. Based on interviews with Staff, interviews with residents, resident admission agreements and LPA observations, the allegation of Facility admitted a resident that is outside the scope of care 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 11/03/2022 LPA Ivey Canady contacted and interviewed administrator for allegations listed in current complaint. Administrator was administrator on record during the time of issue of current complaint. According to interview with the administrator, there were no residents in the facility that had to be hand fed meals. However, during further investigative interviews, Staff 2 (S2) stated R4 does have to be fed meals. Staff 2 described the instances that R4 had to be fed meals. S2 is not the staff person that fed the meals to R4 yet provided the information as a witness statement. Staff 2 described all 3 meals daily to include breakfast, lunch and dinner. On 10/31/2022 LPA visited and toured the facility. LPA requested and received and reviewed LIC602 for R4 during the facility visit.
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 6
Control Number 27-AS-20220601155859
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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Based on LPA review of R4 LIC602, R4 does not require to be hand fed meals. During the tour of the facility, LPA observed R4 during meal time. LPA observed R4 drink the entire volume from a glass, hand self-feed fruit from a fruit bowl and utilize a feeding utensil to feed their self during mealtime. Therefore, based LPA observation, resident record review and staff interviews, the allegation Resident must be fed all meals 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: 5 of 6