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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:34:48 PM


Document Has Been Signed on 02/08/2024 02:34 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: 52DATE:
02/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Melissa Del DossoTIME COMPLETED:
02:45 PM
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On 2/8/24 at 1:00pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to gather additional information regarding control of property and facility name change.

LPA met with executive director Melissa Del Dosso (S1) and together discussed recent changes at the facility and transition to a new management group. LPA provided S1 with required documents needed to make a name change including signatures and approval from the licensee.

LPA discussed control of property and the next steps department and management company will take to ensure the licensee retains control of property to meet regulations. LPA has agreed to reach out to CPMB to expedite administrator certificate so the newly appointed ED can take over the position with department approval.

S1 states that control of property information and name change request documents will be submitted to the department by 2/16/24.

Exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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