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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:03:22 PM


Document Has Been Signed on 09/08/2023 03:03 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: 52DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Benji DoctoleroTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/8/23 at 9:30am to obtain information regarding an Incident Report (SIR) received by Community Care Licensing (CCL) which indicated a medication error occurred. LPA conducted interviews of staff during this visit.

In reviewing the incident report, the medication error occurred on 9/3/23 and was reported to the Administrator via email from the Responsible Party on 9/5/23. This medication error involved resident #1 (R1) receiving a double dose of medication in the morning instead of 1 dose in the morning and 1 dose in the evening as prescribed. The incident report also indicates that all staff working with medication participated in an in-service for medication pass on 9/7/23. The interviews revealed that staff #1 (S1) was told by R1 that there was too many medications. S1 administered the medication without re-checking. Later, R1 was not feeling well and told that to S1. R1's notification to S1 was ignored, not documented, and medical attention was not provided. In addition, during the next shift R1 was provided with the correct dose as prescribed which indicates that R1 received the dose 3 times that day (total of 6 pills: 4 in am and 2 in pm). When the facility staff was notified by the responsible party, an investigation began by S2. S1, confirmed the medication error occurred and medical attention was not provided. Based on the facility investigation, S1 was terminated and medication staff participated in an in-service training as a review of medication processes and protocols. On 9/5/23, when speaking with R1, S3 observed that R1 was at baseline and was able to recall what happened the day of the error. However, the resident was not provided medical attention. Based on the documents submitted to CCL and interviews, the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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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Document Has Been Signed on 09/08/2023 03:03 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87465(j)

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Incidental Medical and Dental Care
In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring ... assisting residents as needed with self-administration of medications...
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Licensee has submitted proof that additional training was provided to medication staff and S1 was terminated.

POC Cleared prior to todays visit
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This requirement is not met as evidenced by: Medication was not administered as prescribed to R1 Based on documentation and interviews which confirmed the medication error occurred
This violation poses an immediate health, and safety risk to residents in care.

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Type A
09/08/2023
Section Cited
CCR87466

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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes...are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee has submitted proof that additional training was provided to medication staff and S1 was terminated.

POC Cleared prior to todays visit
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This requirement is not met as evidenced by: R1 advised S1 of feeling overmedicated Based on interviews, R1 did not receive medical attention after receiving an additional dose of prescribed medication
This violation poses an immediate health, and safety 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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