347005239-10-6-2023-27-AS-KHOS-CWJJA6-20231012065214

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 10/06/2023
Date Signed: 10/06/2023 02:54:00 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
06/29/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230629080317

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: 57	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Benji Doctolero, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/6/23 at 11:00am to conclude a complaint investigation. LPA met with Benji Doctolero, Administrator and stated the purpose of the visit. LPA conducted interviews of Staff #1 (S1) - (S9) and previous Administrator Kayla Davis on 6/29/23. Community Care Licensing received a Death Report (LIC624A) that indicates Resident #1(R1) went to the hospital, admitted for Pneumonia and passed away on 6/24/23. The investigation revealed that R1, was previously admited to the hospital for possibly 3 weeks for swallowing and breathing issues. The physician(s) recommended implementing a g-tube. However, the responsible party declined. R1 was returned to the facility on pureed diet. The S1 instructed staff to the best of their ability keep R1 either sitting up and/or laying to the side when phlegm was present. R1 was able to seek staff assistance when needed. S2, assisted R1 from lying flat to lying to the side to allow phlegm to be discarded.

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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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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Control Number 27-AS-20230629080317

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/06/2023

NARRATIVE

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By 6am, the staff took vitals, the responsible parties were notified of R1s health condition and medical attention was needed. R1 was sent to the hospital for low oxygen, phlegm, swallowing, and to ensure medications for 8am pass would be tolerated. This would be the 2nd time R1 was sent to the hospital for the same issues. As R1, was diagnosed this time with Pneumonia, R1 deceased at the hospital.

Based on interviews and observation, the allegation is deemed UNFOUNDED.

The preponderance of evidence standards has not been met. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Div 6, Ch 8, no violations cited during this visit.

Exit interview conducted copy given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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