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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 11/20/2025
Date Signed: 11/20/2025 04:27:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20251113102732
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:MORENO, ARLENEFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Arlene MorenoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide medications to residents due to inadequate staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Greenhaven Estates RCFE on 11/20/25 at 9:45am to inform the licensee of complaint allegation mentioned above and to deliver findings.

During this investigation LPA Gould interviewed two residents and two staff members. (See confidential name list LIC-811 dated 11/20/25). LPA reviewed multiple incident reports regarding missed medications for residents on 11/1/25. Based on the interviews and statements obtained during the investigation process, the allegation is substantiated. LPA has determined on 11/4/25 no med tech arrived at the facility to assist residents in assisted living with medications. As a result multiple residents in assisted living did not receive morning medications. As part of this investigation the department has also determined the facility did not report the missed medications in a timely manner to the department per regulations.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
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 7
Control Number 27-AS-20251113102732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2025
Section Cited
CCR
87464(f)(1)
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Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by incident reports and resident statements that on 11/1/25 no
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Administrator has agreed to provide a shift change plan including documented lead med techs and caregivers to lead the shift change and contact executive team should there be a staff absence or shortage of resident care needs by the POC due date 11/21/25
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med tech arrived to provide medications for residents in assisted living which resulted multiple residents not receiving their medications for the morning of 11/1/25 which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
11/21/2025
Section Cited
CCR
87413(a)(1)
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Personnel - Operations: When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by facility produced incident
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The facility has begun the process of constraining caregivers to complete the duties of medication administration in the event of an absence of a med tech on a future date. Provide a training plan by the POC due date 11/21/25.
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reports and resident statements that there was no coverage available to ensure residents in assisted living received their morning medications which poses an immediate health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20251113102732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not
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facility has agreed to post the weekly schedule with sign up space available for any coverage needed on a weekly or daily basis.
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met as evidenced by incident reports and resident and staff statements corroborating there was no AM med tech to provide medications to residents in care which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
12/05/2025
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age,
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The facility is hiring a new position to take of the duties of Assisted living director who will be trained on documenting incident report and all reports will be reviewed by administrator prior to submitting to the department.
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sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case...Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. this requirements was not met as evidenced by LPA receiving Incident reports 17 days after the reported incident occurred which poses a potential health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20251113102732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2025
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA review of resident MARs which shows
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Administrator has agreed to complete retraining for all med tech staff specificity in regard to timely documentation of medication administration.
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 staff are not documenting medications administered to residents timely as LPA observed some medications documented administered up to 4 hours after the medication was to be provided to the resident which poses a potential health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20251113102732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
VISIT DATE: 11/20/2025
NARRATIVE
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In review of medication administration records for one resident, LPA observed the facility is not appropriately documenting medications administered to residents as they are administered and LPA observed multiple dates where staff members did not document a medication after administered an would document the medications several hours after administered to residents in care. department also observed that there is no weekly staff schedule posted in a place where staff may observe the weekly schedule.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of medications is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/13/2025 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20251113102732

FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:MORENO, ARLENEFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Arlene MorenoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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2
3
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5
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9
Staff did not answer residents' pendents in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Greenhaven Estates RCFE on 11/20/25 at 9:45am to inform the licensee of complaint allegation mentioned above and to deliver findings.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA reviewed the Pendant call log system for several residents and observed no significant delays for call pendant response times. LPA also reviewed the front desk log that tracks open call pendants for staff and observed no excessive wait times for completed services. LPA conducted interviews with three residents who did not identify any significant delays or complaints regarding call light responses from staff members.

Report Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20251113102732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
VISIT DATE: 11/20/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7