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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 06/28/2023
Date Signed: 06/28/2023 05:20:04 PM


Document Has Been Signed on 06/28/2023 05:20 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
SACRAMENTO AC/SC, 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:
06/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Kayla DavisTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on an incident report. LPA Moleski met with administrator Kayla Davis and explained the purpose of the visit.

The incident report states that on 2/4/23, a resident (R1) notified staff that R1 had found a thumb tack at the bottom of a bowl of fruit. The incident report states that R1 was not hurt, and that staff replaced the meal. According to the incident report, executive director Davis instructed staff to remove any thumb tacks in the kitchen.

LPA Moleski inspected the kitchen, and found several items posted with thumb tacks. Davis showed LPA Moleski the counter believed to have been used while serving R1 the bowl of fruit. LPA Moleski observed several pin-holes in the wall immediately above the countertop. LPA Moleski photographed the postings with thumb tacks, the countertop, and the pin-holes.

Davis produced the thumb tack found in the fruit bowl. LPA Moleski photographed the tack. The facility investigated the incident internally and did not find any other thumb tacks matching that color, according to Davis.

LPA Moleski interviewed R1. LPA Moleski interviewed two kitchen staff (S2-S3) and asked them about the counter identified by Davis as the counter believed to have been used while preparing the bowl of fruit served to R1. S2 said menus have been posted above the counter using thumbtacks in the past.

This facility is being cited per 22 CCR 87555(a). An exit interview was held with Davis. Appeal rights and a copy of this report were left with Davis.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/28/2023 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2023
Section Cited
CCR
87555(a)

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General Food Service Requirements: "(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner."
This requirement was not met as evidenced by:
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Licensee agrees to remove all thumb tacks from kitchen and to send LPA Moleski a staff training record for dining staff regarding this incident.
vincent.moleski@dss.ca.gov
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Based on review of the facility's incident report, a resident was served food that was not safe for consumption, which poses an immediate health and safety risk.
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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: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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