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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:19:21 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/20/2024 03:19 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:DEBRA DUVALFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 57DATE:
06/20/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Debra DuvalTIME COMPLETED:
03:30 PM
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On 6/0/24 at 12:45pm Licensing Program Analyst (LPA) Kevin Gould arrived at Greenhaven Estates for the purpose of conducting a continuation of the required 1 year annual inspection begun on 5/24/24. LPA met with Administrator, Debra Duval and together conducted a tour of the facility.

LPA Gould completed file review of resident files. LPA observed most files to be complete with one resident requiring an updated LIC 602 as it was over a year old and is in need of renewal. Advisory note issued.

Per California Code of regulations title 22, there were no deficiencies cited during today's inspection.

Exit interview conducted and a copy of the 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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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