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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 08/16/2021
Date Signed: 08/16/2021 05:28:43 PM

Document Has Been Signed on 08/16/2021 05:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:DONNA BAUTISTA-COLMENARESFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 105CENSUS: 53DATE:
08/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Donna Bautista-Colmenares TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 8/16/21 at 1pm. LPA met with Donna Bautista-Colmenares and stated the purpose of the visit.

Community Care Licensing (CCL) received an Incident Report indicating that on 9/25/2020, Resident #1 (R1)'s Narcotic Hydrocodone-Acetaminophen 5-325 MG Tabs had one missing from the bubble pack.

A narcotics count was being conducted during shift change when S1 and S2 noticed there was one missing on 9/25/2020. In addition, R1 was admitted to the hospital for tests following an appointment on 9/23/2020 according to facility Charting Notes and on 9/26/2020 would be discharged to skilled nursing as a result of the testing.

During a Medication Record review with the Administrator it was determined that the medication was last administered on 9/23/20 to R1. Staff #1 (S1) and (S2) were drug tested and both results were negative. S3 left the shift early without informing supervisors on 9/24/20 during the PM shift.

Administrator stated that S3 was not drug tested and was scheduled to be terminated. The missing medication occurred from a staff member of the facility. In addition, the Administrator stated that she is sure the physician and family were notified. However, this was not mentioned on the incident report.

Based on observation, interview, and documentation the preponderance of evidence standards has not been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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Document Has Been Signed on 08/16/2021 05:28 PM - It Cannot Be Edited


Created By: Victoria Brown On 08/16/2021 at 04:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2021
Section Cited
CCR
87468.1

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Residents in all residential care facilities for the elderly shall have all of the following personal rights:To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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Licensee shall submit in writing a plan on when training will be provided to those submitting Incident Reports to CCL that a complete SIR will be submitted on every occurrence and PCP and RP will be notified. The training documentation to be submitted by 8/24/21.
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This requirement is not met as evidenced by: Incident Report does not mention Physician and/or Responsible parties were notified of the missing medication
Based on interview with Administrator and observation of the SIR Licensee did not ensure PCP and RP were notified
This posed an immediate health and safety risk to residents in care.
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Type A
08/17/2021
Section Cited
CCR87411(f)

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Personnel Requirements - General All personnel...good health, and physically and mentally capable of performing assigned tasks. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
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Licensee shall submit a written notice that the staff has been terminated and removed from facility roster. To be submitted by 8/24/21.
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This requirement is not met as evidenced by: Staff left facility during work shift
Based on interview with Administrator staff left before going through termination process no documentation to prove termination happened.
This posed an immediate health and safety risk to residents in care.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2021


LIC809 (FAS) - (06/04)
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