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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:24:14 PM


Document Has Been Signed on 03/08/2023 12:24 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:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 51DATE:
03/08/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kayla DavisTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 3/8/23 at 9:45am. LPA met with Kayla Davis and stated the purpose of the visit. This visit is to ensure that the care home is meeting the terms and conditions of its probationary license effective 6/18/2020 to 6/18/2023. Licensed to serve 105 Non-Ambulatory residents ages 60 and above of which 4 maybe bedridden and 12 may receive hospice care services. There are 6 on hospice at this time. Administrator certificate expires on 1/16/24.
Per stipulation, LPA observed stipulation posted, incidents are reported by next working day and a written report is submitted within seven days, monthly staff training's are being conducted. The imposed staff to client ratio is being upheld for both the memory care and assisted living units, audits of medication and records are being conducted. LPA observed, assessed and communicated with a random amount of residents present during this visit. LPA and Administrator toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed the storage areas, a random amount of bedrooms and bathrooms, required furniture and lighting, equipment such as stove, and refrigerator(s) to be operable and knives were inaccessible during this visit. The temperature inside the facility was measured at 74*F on the thermostat on the wall of the facility which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C). The hot water was measured at 114.8*F in room 158 and 113.5*F in room 145 which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.
LPA observed oxygen signs posted for those who are using oxygen and the tanks are secured during this visit.
LPA observed the 7 day non-perishables and 2 day perishables on site.
The medications were found locked and inaccessible. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA reviewed submitted documents and incident reports submitted to Community Care Licensing (CCL). Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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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