347005239-7-17-2024-27-AS-KHOS-D83RUG-20240812131954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:54:17 PM

Substantiated

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
03/13/2024 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20240313141059

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: 53	DATE:	07/17/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Debra Duval		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Neglect/Lack of Supervision: Staff did not respond to resident’s pendant call.

Physical Plant: Facility elevator is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Greenhaven Estates RCFE on 7/17/24 at 9:00am to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with administrator, Debra Duval and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA Gould conducted interviews with five staff staff members, Adult family member, and four residents. All residents interviewed identified delays in call response times resulting in residents waiting for care and in some cases resulting in soiling themselves awaiting toileting assistance. Three of the staff members interviewed identified responding to calls for service as a need not currently being met by staff members as they are unable to respond to all calls in a timely manner due to other duties of care and supervision required for residents in care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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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Control Number 27-AS-20240313141059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2024

NARRATIVE

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The adult family member interviewed also corroborated that call pendants were not responded to when family member had to use the restroom and could not locate any staff on the floor which resulted in resident soiling their briefs.

In regards to the elevator not working or in disrepair, LPA conducted staff interview with former administrator who provided documentation that the elevator was inspected by state inspectors in 2023 and identified a phone system not working and required to be operational or the elevator would be deactivated. In March 2024, state inspectors returned and observed the phone system in the elevator to still not be operational and deactivated the elevator. The elevator was reactivated a few days later and the telephone was fully repaired and operational by March 26, 2024. LPA has determined the facility's delay in repairing the elevator phone was the cause of the elevator shut down in March 2024.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision and Physical Plant is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240313141059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/26/2024 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by statements obtained from staff members, residents and family	1 2 3 4 5 6 7	An updated written plan of correction will be submitted with an updated plan for responding to calls for assistance.
	8 9 10 11 12 13 14	members that facility has delays in response to calls for service which resulted in resident's needs not being met in a timely manner.	8 9 10 11 12 13 14
Type B 07/26/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by documents	1 2 3 4 5 6 7	A written plan of correction shall be submitted by the facility indicting the steps facility will take including timelines for outreach and contracting with vendors for physical plant maintenance.
	8 9 10 11 12 13 14	obtained from the facility indicating the state required elevator repairs in 2023 which were not completed in a timely manner resulting in the elevator being shut down in March 2024 by the state until repairs have been completed which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14

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: 07/17/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC9099 (FAS) - (06/04)

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