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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:31:38 PM


Document Has Been Signed on 07/17/2023 03:31 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: 46DATE:
07/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alexandria RodriguezTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit to follow up on two incident reports. LPA Moleski met with regional nurse Alexandria Rodriguez and explained the purpose of the visit.

Both incident reports described incidents that occurred on October 20, 2022. A resident (R1) reported missing money to the facility's former executive director on this date. LPA Moleski reviewed an SOC 341 filed regarding this incident which stated the missing money totaled $135. R1 last saw the money on 9/29/22, and noticed it was missing on 10/12/22, according to the SOC 341. Another resident's (R2) responsible party reported missing credit cards to the facility's former executive director on 10/20/22. Police reports were made for both incidents, according to the incident reports.

R2 died on November 18, 2022. LPA Moleski interviewed R1 and R3. R2 was R3's spouse. R3 did not recall the missing credit cards.

R1 did recall the missing money, and suspects it was stolen.

LPA Moleski reviewed the facility's theft and loss procedures as stated in the facility plan of operation. LPA Moleski requested copies of the police reports for each incident.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Rodriguez.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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