347005239-4-24-2023-27-AS-KHOS-CRGLX7-20230503090817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 02/24/2023
Date Signed: 04/24/2023 04:55:03 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
01/30/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230130162646

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	KAYLA DAVIS		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 51	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kayla Davis		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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incontinent needs not being met
call light not being answered timely
staff member is disrespectful
medical needs are not being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 4/24/23 at 1pm. LPA met with Kayla Davis, Adminstrator and stated the purpose of the visit.

LPA conducted interviews during this visit of Staff (1)-(5), Administrator, and Residents (1)-(3).

Regarding allegation, "incontinent needs not being met", LPA interviewed R1-R3 all of whom concur that their incontinence care response time from staff is prolonged as to where there is urination accidents,

Regarding allegation, "call light not being answered timely", LPA interviewed R1-R3 and S4 all of whom concur the call lights are not being answered timely which included the most recent incident which occurred last night where R1 was told by the NOC shift that the call light wasnt working until the morning,

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: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 4

Control Number 27-AS-20230130162646

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: 02/24/2023

NARRATIVE

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Regarding allegation, "staff member is disrespectful", LPA found through interviews that S1, S2 and R1-R3 concur that caregivers were in fact being disrespectful during activities of daily living assistance for R1-R3.

Regarding allegation, "medical needs are not being met", LPA observed Resident #2's Interim Service Plan which indicated that as of 1/28/23, R2 was prescribed antibiotics (10 days) for a infection. The instruction to facility was to report any increased symptoms such as swelling, redness, pain, odor, drainage, oozing, or tenderness. Based on the review of facility Charting Notes for 1/28/23 - 2/7/23, LPA observed the foot was soaked in Epsom salt once during the 10 days on 1/31/23. On the Physician Orders for medications, LPA observed physician stated resident can clearly communicate the need for a nonprescription medication, however, LPA did not observe any authorization or communication with the physician to use Epson salt soak for R2.

The investigation revealed that the Administrator was made aware of the incidents and acted on behalf of the facility and residents and the decision was made to terminate S1 and S2.

Based on interviews, and documentation the preponderance of evidence standards has been met; therefore, the above allegation(s) is found to be SUBSTANTIATED.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20230130162646

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: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2023 Section Cited CCR 87459(a)(5)(A)	1 2 3 4 5 6 7	Functional Capabilities The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: Continence, including: Bowel and bladder control.	1 2 3 4 5 6 7	Licensee shall provide an in-service to all staff regarding personal rights by POC due date to be submitted via fax.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by:interviews confirmed that residents had urinary accidents due to staff not assisting for long periods of time Based on staff did not provide incontinence care timely This violation poses a potential health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 04/28/2023 Section Cited CCR 87464(a)	1 2 3 4 5 6 7	Basic Services The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community.	1 2 3 4 5 6 7	Licensee shall provide an in-service to all staff regarding personal rights by POC due date to be submitted via fax.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The call light was working but the staff was not responding Based on interviews confirmed that these incidents occurred for at least 3 residents This violation poses a potential health, and safety risk to residents in care.	8 9 10 11 12 13 14

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: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20230130162646

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: 02/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from...humiliation...interfering with daily living functions such as ...elimination.	1 2 3 4 5 6 7	Licensee shall provide an in-service to all staff regarding personal rights by POC due date to be submitted via fax.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Interviews of staff and residents confirmed staff was speaking to residents in a disrespectful manner Based on interviews staff did not provide dignity to residents in care This violation poses a potential health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 04/28/2023 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental Care For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.	1 2 3 4 5 6 7	Licensee shall provide an in-service to all staff regarding PRN medication by POC due date to be submitted via fax.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: staff provided PRN assistance without prescription Based on documentation did not indicate approval to assist resident with PRN medication This violation poses a potential health, and safety risk to residents in care.	8 9 10 11 12 13 14

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: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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