347005239-6-29-2023-27-AS-SRIN-CU4UXW-20230726155859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:02:44 PM

Unfounded

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
02/16/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230216131323

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: 49	DATE:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	02:42 PM
MET WITH:	Kayla Davis		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is not following resident's prescribed diet
Resident room had mold growing from flooded floor
Facility is not adequately staffed
Facility is not providing training for resident transfers
Facility does not respond to call pendents timely
Facility did not ensure resident safety resulting in serious injuries
Facility did not notify POA of hospitilization
False statement
Facility did not ensure resident rooms were safe, tripping hazards were presented
Facility is not following resident's prescribed diet
Resident room had mold growing from flooded floor
Facility is not adequately staffed
Facility is not providing training for resident transfers
Facility does not respond to call pendents timely
Facility did not ensure resident safety resulting in serious injuries
Facility did not notify POA of hospitilization
False statement
Facility did not ensure resident rooms were safe, tripping hazards were presented
Facility did not ensure electriciy is working in resident rooms
Facility is not reporting incidents to CCL
Facility did not provide explanation of increase in rent to POA
Administrator did not notify POA and resident of Probationary License prior to admittance
Facility did not ensure resident received instructions during fire drill

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to deliver an UNFOUNDED finding for this complaint. On 4/27/23, LPA observed while speaking with complainant that this complaint was written and opened under the wrong facility number.

Based on the above mentioned information, the allegations is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint.

Per California Code of Regulations, no deficiencies were observed. Exit interview held, and a copy provided.

Unfounded

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: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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