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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:34:57 PM


Document Has Been Signed on 09/07/2023 03:34 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:BENJI DOCTOLEROFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 51DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Benji DoctoleroTIME COMPLETED:
10:57 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/7/23 at 8:30am to conduct a Case Management visit. LPA met with Administrator Benji Doctolero and stated the purpose of the visit.

LPA inquired if staff #1 (S1) was presently on the premises during this visit. Administrator Benji Doctolero stated the staff has never worked for the Licensee.

LPA served notice of "ORDER TO INDIVIDUAL OF IMMEDIATE EXCLUSION" for S1 who was not present at the time of visit. Administrator was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S1 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL).

LPA informed Administrator that S1 is not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion came into effect as of 09/05/2023 upon receipt of the letter. A copy of the letter was given to the facility during this visit.

The facility understands this is an Immediate Exclusion and has agreed S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed and cited.

Exit interview held, A Copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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