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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
347005239
Report Date:
05/24/2024
Date Signed:
05/24/2024 04:08:16 PM
Document Has Been Signed on
05/24/2024 04:08 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 ESTATES
FACILITY NUMBER:
347005239
ADMINISTRATOR:
DEBRA DUVAL
FACILITY TYPE:
740
ADDRESS:
7548 GREENHAVEN DR
TELEPHONE:
(916) 427-8887
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95831
CAPACITY:
105
CENSUS:
62
DATE:
05/24/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:15 AM
MET WITH:
Debra Duval
TIME COMPLETED:
04:30 PM
NARRATIVE
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On 5/24/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at
Greenhaven Estates for the purpose of conducting a required 1 year annual inspection. LPA met with Administrator, Debra Duval and together conducted a tour of the facility.
LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture. LPA observed several lights out in common areas and hallways.
LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.
LPA observed cleaning supplies and sharp objects not secured from residents in the activity room, laundry room and kitchen storage room. LPA observed gloves not disposed of in a manner consistent with department infection control, LPA observed gloves in common area drawers. LPA observed two showers in Memory care without non-slip mats or strips on the floors. During staff file review LPA observed several staff files without health screening, tb test and first aid certificates. LPA was unable to verify staff training's meet requirements as staff present did not have access to all resident files at the time of inspection.
SUPERVISOR'S NAME:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as LPA observed cleaning supplies and sharp object accessible to residents in the activity room, laundry room and kitchen storage area which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/28/2024
Plan of Correction
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Facility will conduct training with all staff members to inform staff where items to be secured from residents may be stored and ensuring the doors are always locked. facility will provide documentation of training of all staff members to the department.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as LPA observed the kitchen storage to not be locked containing multiple drawers of sharp knives which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/28/2024
Plan of Correction
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Facility will conduct training with all staff members to inform staff where items to be secured from residents may be stored and ensuring the doors are always locked. facility will provide documentation of training of all staff members to the department.
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 6 staff files reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/28/2024
Plan of Correction
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Facility will conduct training from an outside provider and renew first aid certificates for all staff members. All certificates will be placed in staff files for department review.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(4)(C)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (C) Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required by subsection (a)(4)(A) with one resident and prior to an interaction with another resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above as LPA observed several gloves disposed of in common area drawers and furniture which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/12/2024
Plan of Correction
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Facility will conduct infection control training for all staff regarding the proper disposal, downing and doffing of PPE.
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations the licensee did not comply with the section cited above as LPA observed several common area hallway lights out and not working as designed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
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Facility will ensure lighting in all common areas and resident bedroom are working and operating as intended.
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations of memory care showers the licensee did not comply with the section cited above in two out of for bathroom showers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2024
Plan of Correction
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facility will install non slip matt or strips an all bathrooms and showers.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA was unable to review all staff files as the staff present did not have access to all staff file the department is required to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
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Written plan of correction to ensure administrator and their designee have access to all resident and staff records and be made available for department review.
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 6 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2024
Plan of Correction
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Facility has agreed to evaluate and inventory all staff and have ha health screening conducted and TB test completed for all staff who do not have a completed LIC 503 and do not have a TB test and all staff members who's TB test was conducted in house and not conducted by a licensed physician.
Section Cited
Deficient Practice Statement
1
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
05/24/2024 04:08 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:
05/24/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as there was no documentation for hands on training for any of the staff files reviewed by LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/28/2024
Plan of Correction
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Facility will review staff training records and will provide the department a written plan of correcting indicating the steps the facility will take to ensure staff receive and document 16 hours of hands on training.
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:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
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
VISIT DATE:
05/24/2024
NARRATIVE
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LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate.
Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility. An annual continuation will be required to complete the annual inspection.
SUPERVISOR'S NAME:
Czarrina A Camilon-Lee
TELEPHONE:
(916) 214-5136
LICENSING EVALUATOR NAME:
Kevin Gould
TELEPHONE:
(619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8