347005239-5-27-2021-27-AS-KHOS-C3LKZH-20210602082045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 05/27/2021
Date Signed: 05/27/2021 01:42:37 PM

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
11/18/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20201118080436

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: 45	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Inappropriate restraint used by staff on resident
Facility failed to provide adequate food service
Staff failed to administer resident's medication in a timely manner
Facility is unclean
Facility smells bad from dog feces
Facility failed to meet the needs of the residents by providing activities

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/27/2020 at 1:00pm to conclude the investigation the above-mentioned allegations. LPA met with Donna Bautista-Colmenares and discussed the purpose of the visit. Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? No Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea No Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

Unsubstantiated

Estimated Days of Completion: 190

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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-20201118080436

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: 05/27/2021

NARRATIVE

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On 5/18/21, LPA requested, received, and reviewed a copy of roster of staff with contact information and a roster of residents residing in the facility.

In regards to allegation, “Inappropriate restraint used by staff on resident” During interviews of S1-S8 all concur that the resident was not put at the table in a wheelchair leaning forward with hands behind the back by anyone. It was stated that the resident would not sit at the table longer than 1 hour either for breakfast or lunch due to leg pain.
In regards to allegation, “Facility failed to provide adequate food service” During interviews of S1-S8 all concur that the residents was provided a variety of juices and water that was offered and given throughout the day. There were no residents that had their food prepared into smaller portions.

In regards to allegation, “Staff failed to administer resident's medication in a timely manner” During interviews of S1-S8 all concur that the resident did not miss any medications and would insist on not eating prior to 10am before taking the medication.

In regards to allegation, “Facility is unclean” During interviews of S1-S8 all concur that the facility was kept clean by caregivers and housekeeping on a daily basis.

In regards to allegation, “Facility smells bad from dog feces” LPA obtained information that the Administrator brought a dog to the facility but it was kept in the Administrators office. During interviews of S1-S8 all concur that the facility did not smell of feces and the dog was kept in the Administrators office.
In regards to allegation, “Facility failed to meet the needs of the residents by providing activities” During interviews of S1-S8 all concur that the facility did work with residents while doing activities in the memory care unit and assisted living area. A variety of activities were offered and conducted after breakfast and throughout the day.

Based on interviews conducted of staff 1-9, and lack of evidence the preponderance of evidence standards has not been met. The allegation(s) are UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

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