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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 11/03/2023
Date Signed: 11/27/2023 10:03:05 AM

Substantiated


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
06/28/2023 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230628100035
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 55DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alexandria Noel, Business Office Manager/AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Night shift staff sleeping
INVESTIGATION FINDINGS:
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THIS REPORT IS AMENDED TO STATE THE PRINCIPLES OF DOCUMENTATION FOR SUBSTANTIATED ALLEGATION. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above-mentioned allegation on 11/3/23 at 8:30am. LPA met with Alexandria Noel, Business Office Manager/Administrator and stated the purpose of the visit. Regarding allegation, “Night shift staff sleeping”, LPA received a photo of Staff #1 (S1) sleeping on a sofa in the facility. S1 was identified by Benji Doctolero, Administrator (BD). Administrator BD became aware these staff are no longer working at the facility. Based on interviews, and photo of S1 identified, allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per CCR Title 22, Div 6, Ch8, the following deficiencies are cited on the attached 9099D 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 with 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.


Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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 5
Control Number 27-AS-20230628100035
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2023
Section Cited
CCR
87466
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Observation of the Resident

The licensee shall ensure that residents are regularly observed...
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Licensee/Administrator laid off or terminated pertinent staff prior to todays visit.

POC cleared prior to todays visit.
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This requirement is not met as evidenced by: Based on interviews confirming staff were sleeping during their shift. This 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: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
06/28/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230628100035

FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 53DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alexandria Noel, Business Office Manager/AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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5
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9
Staff inappropriately handle residents roughly causing bruising
Staff inappropriately use children to care for residents
Staff maintain expired medications
Staff leave medication accessible to residents in care
INVESTIGATION FINDINGS:
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5
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10
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13
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 11/3/23 at 8:30am. LPA met with Alexandria Noel, Business Office Manager/Administrator and stated the purpose of the visit.

Regarding allegation, “Staff leave medication accessible to residents in care”, LPA observed through interviews of S1-S6 had conflicting information. One of the 6 identified one particular staff. Two of the 6 interviewed stated the medication room door was left open by a staff from an agency. While Three of the 6 had no knowledge of a time that it occurred. LPA did not obtain a preponderance of evidence.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230628100035
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: 11/03/2023
NARRATIVE
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Regarding allegation, “Staff inappropriately handle residents roughly causing bruising”, during interviews with S1-S6, of which 2 stated they heard that skin tears occurred and 1 stated bruising occurred from assisting with the dementia diagnosed residents none of which was a result of abuse or rough handling. LPA did not obtain a preponderance of evidence.

Regarding allegation, “Staff inappropriately use children to care for residents”, LPA did not observe a preponderance of evidence based on interviews of staff (S1-S6). LPA obtained information through interviews that children were allowed to be present during special events and only in those areas and not allowed to assist residents.

Regarding allegation, “Staff maintain expired medications”, LPA requested and observed a random amount of Medication Destruction Record of medications for resident #1(R1-R5) which had the most recent disposal dates of 5/27/23, 6/20/23, 6/22/23, 6/24/23, 5/14/22. LPA obtained a photo which indicates medications were in a white plastic bag. However, it is unclear where the items were located. LPA obtained information through interviews that expired medications are held in a medication container and are stored in a locked area of which there is 1 key only available to Medication Technicians, and Resident Care Coordinator. When caregivers need anything from that area, someone would get it for them. LPA observed the area where medications are discarded and they are in the red hazardous material containers. LPA did not observe medications in plastic bags in neither Memory Care, Assisted Living, supply room, nor housekeeping area. LPA did not obtain a preponderance of evidence.

Based on interviews and lack of evidence the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.
An exit interview was conducted, and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/28/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20230628100035

FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:KAYLA DAVISFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 53DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alexandria Noel, Business Office Manager/AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above mentioned allegations on 11/3/23 at 8:30am. LPA met with Alexandria Noel, Business Office Manager/Administrator and stated the purpose of the visit.

Regarding allegation, “Questionable death”, LPA observed that this allegation was investigated as an allegation on another complaint. The allegation was deemed Unfounded on 10/6/23 under Complaint Control Number 27-AS-20230629080317.
Based on the above mentioned information, the allegations is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations, no deficiencies were observed or cited.

Exit interview held, and a copy provided.
Unfounded
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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 5