Community Care Licensing

Document Has Been Signed on 10/22/2021 01:46 PM - It Cannot Be Edited

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DONNA BAUTISTA-COLMENARES		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY: 105		CENSUS: 54	DATE:	10/22/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	01:15 PM

SUPERVISORS NAME: Stephen Richardson LICENSING EVALUATOR NAME: Victoria Brown LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021

Link to Parent Document Below:

FACILITY NAME: GREENHAVEN ESTATES	FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/25/2021 Section Cited CCR 87405(a)	1 2 3 4 5 6 7	Administrator - Qualifications and Duties All facilities shall...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...	1 2 3 4 5 6 7	Licensee shall submit LIC308 designating who will be responsible for the facility during the absence of the Administrator by POC due date.by fax.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: During the CM visit there was no LIC 308 designating anyone Based on Facility staff did not have knowledge of the LIC 308. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 10/25/2021 Section Cited CCR87411(d)(4)	1 2 3 4 5 6 7	Personnel Requirements - General All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:Knowledge required to safely assist with prescribed medications which are self-administered.	1 2 3 4 5 6 7	Licensee shall submit a plan on when the training will be conducted with all staff handling medications to ensure processes are understood and utilized at all times. Training to be completed by POC due date and confirmation with signatures to be faxed by 10/29/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: During the CM visit the staff and LPA observed discrepancies in the medication room. Based on Facility staff and LPA found pill container/container slot for R1 had two different room numbers, 2 cups did not have a name on it, 1 cup did not have a lid with pills inside with a small paper cup on top of the pills, staff was unable to explain the system of using the bubble pack. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Stephen Richardson LICENSING EVALUATOR NAME: Victoria Brown LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021