347005239-12-20-2023-27-AS-SRIN-CYXSRZ-20231228130711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:21:31 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230925093154

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	BENJI DOCTOLERO		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 50	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alexanderia Noel		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not ensure that residents are provided care in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude a complaint investigation on 12/20/23 at 9:30am. LPA met with Alexandria Noel, Administrator and stated the purpose of the visit. LPA requested the following documents. Resident roster and staff roster with contact information. LPA reviewed the Caregiver schedule for September 2023 which showed Staff #1 (S1-S8) to be on schedule from 6-2:30pm. S2 and S3 called out, S4 didnt work the day of 9/22/23 which left S1 on the schedule as the only person scheduled to work on the Assisted Living side. However, S9-S11 were working on the Memory Care side of the building. During interviews, staff stated that on a daily basis, staff on both sides help each other when necessary. This particular day, although there were call outs there were additional staff (S5-S8) who assisted with resident needs. The investigation revealed that staff was available to assist with resident care needs during the absence of the 2 staff call outs. See 9099C for continuation...

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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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-20230925093154

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/20/2023

NARRATIVE

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9099 Continued...

In addition, LPA was informed that during the time of receiving this complaint, everyone (staff and residents) were upset because of layoffs due to having a low census. LPA was also informed during an interview today that the residents were fine.

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

The allegation 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.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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