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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:21:50 PM


Document Has Been Signed on 12/14/2023 04:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 49DATE:
12/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adriana Vue (LVN) Interim Assisted Living Director (ALD).TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/14/23 at 9am on a subsequent visit. Upon arrival LPA received information that the previous Administrator Benji Doctolero is no longer working for the facility. Alexandria Noel, was interim but is now on leave of absence. These two were designated on the LIC308. During this visit, LPA met with Bradley Boyer, Executive Chef/Culinary Director and Adriana Vue (LVN) Interim Assisted Living Director (ALD). LPA stated the purpose of the visit.

LPA obtained additional information that Arlene Moreno Assisted Living Director is on leave of absence and Tyler Brown Residential Care Coordinator is not in office today. LPA observed Lindsey Palmer Director of Sales & Marketing showing facility to potential new resident.
The facility was provided the pertinent information below regarding submission for change in Administrators and/or Executive Directors.
-Ensure the person is fingerprint cleared and associated to the facility through your Guardian account
-Submit all documents mentioned below:
Administrator Certificate, Personnel Record (LIC501), Health Screening with TB (LIC503), CPR/First Aid, Designation (LIC308), A letter from the Licensee appointing the person to be able to speak on behalf of the Licensee, Updated Personnel Report (LIC500) showing the Administrator on schedule in the facility 40hrs per week.
These documents are to be submitted as well as notification to the Department any time there is a change or intended change in the Administrator and/or Executive Director.

Based on information obtained and a review of the posted LIC308, 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 facility representative 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: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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 12/14/2023 04:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator...shall be on the premises...When the administrator is not in the facility, there shall be coverage by a designated substitute...accountable for management and administration of the facility
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Licensee/Administrator shall submit by fax in writing the plan to secure a currently certified administrator. In addition, submit an updated LIC308 by fax by POC due date.
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This requirement is not met as evidenced by: Based on observation and interviews which confirmed the absence of an Administrator of record on file with CCL or a designee.
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: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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