347005239-12-14-2023-27-AS-SRIN-CYXS7W-20231228123814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:27:51 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
08/21/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20230821115041

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: 49	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Adriana Vue (LVN) Interim Assisted Living Director (ALD).		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff is stealing a resident's money
Staff is rough with a resident
Staff neglected resident resulting in a fall

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/14/23 at 9am to conclude an investigation of the above-mentioned allegations. LPA met with Adriana Vue (LVN) Interim Assisted Living Director (ALD) and stated the purpose of the visit.
LPA conducted interviews on 8/21/23 with previous Administrator Benji Doctolero, residents #1 (R1-R4) and staff #1 (S1- S6). LPA also received rosters of residents, roster of staff with contact information, and the Notice of Employee as to change in Relationship notice. Regarding the allegations mentioned above, “Staff is stealing a resident's money, Staff is rough with a resident, and Staff neglected resident resulting in a fall”, LPA was unable to obtain a preponderance of evidence. Based on interviews of staff (S1-S6), residents (R1-R4), and review of Notice to Employee the allegations mentioned above 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 (CCRs) - Title 22, Div.6, Ch. 8, no deficiencies are being cited. An exit interview was conducted, and a copy of this report was provided.

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: 12/14/2023

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.

LIC9099 (FAS) - (06/04)

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