347005239-6-3-2021-27-AS-SRIN-C3T3U6-20210608183259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 06/03/2021
Date Signed: 06/03/2021 09:52:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2020 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20200706094551

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DALE MASTERS		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 46	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Administrator Donna Bautista-Colmenares		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not administer residents medication in a timely manner
Staff did not answer residents call button in a timely manner

INVESTIGATION FINDINGS:

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On 06/03/21 at 9:25 AM, Licensing Program Analyst (LPA) Christina Valerio and LPA Suong Teh conducted an unannounced facility visit to deliver complaint investigation findings. LPA Valerio and Teh met with Administrator (ADM) Donna Bautista-Colmenares. The investigation was conducted by LPA Victoria Brown and LPA Christina Valerio and consisted of interviews with Administrator(s) (S1- S2) and facility staff (S3-S7). Medical and facility records were obtained and reviewed.

LPA has determined the following as it relates to the above complaint allegations.

Dale Masters (S1) was the Administrator at the start of the investigation. Dale was terminated in October 2020. Administrator Donna Bautista (S2) was not the administrator at the time of complaint.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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-20200706094551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GREENHAVEN ESTATES	FACILITY NUMBER: 347005239
	VISIT DATE: 06/03/2021

NARRATIVE

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Continued from LIC 9099- C, page 2...

LPA Valerio attempted to interview four residents (R1-R4). After 3 failed attempts for R1 - R4, LPA concluded all interviews to be unsuccessful.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Administrator Donna Bautista-Colmenares.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200706094551

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GREENHAVEN ESTATES	FACILITY NUMBER: 347005239
	VISIT DATE: 06/03/2021

NARRATIVE

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Continued from LIC 9099...

On 07/16/2020, LPA Victoria Brown interviewed previous Administrator (S1) Dale Masters. Dale Masters reported that staff did not report any medication errors or missed medication dosages in 2020. Dale stated that residents have not reported any missed medications in 2017. In regard to staff not answering residents call button, Dale stated that the facility uses Cisco system. It has had no reported issues.

LPA Valerio interviewed 5 facility staff members (S3 - S7). On 04/18/21, LPA Valerio spoke to Staff 3 (S3). S3 informed LPA that all documentation for resident's medications are logged into the computer anytime there is a medication hold, medication refusal, or missed medication dose. S3 stated that caregivers respond to the resident's call notification within 3 to 7 minutes, on average. If the caregivers are busy, medication technicians are back up. On 04/28/21, LPA Valerio spoke to Staff 6 (S6). S6 stated that caregivers do not handle medication duties; therefore, she cannot report on how medications are handled. S6 stated caregivers have a maximum of 10 minutes to respond to a resident's call, but estimated time for response is 3 to 5 minutes. If a caregiver is busy helping a resident, there are two other caregivers and a medication technician who can answer the call. Once the call is answered, staff enter notes describing reason for call on the facility iPad. LPA Valerio attempted to interview Staff 4 (S4), Staff 5 (S5), and Staff 7 (S7); however, after 4 failed attempts, the interviews were deemed unsuccessful.

LPA Valerio reviewed facility files. Staff schedules showed adequate staffing coverage for June 2020 and July 2020 for the Memory care and Assisted Living sides of the facility. Current Administrator Donna did not have access to the call button records for 2020; therefore, 3 months of calls button logs for 2021 were provided. Call button records for January 2021, February 2021, and March 2021 show that majority of calls were responded within 10 minutes of a resident pressing the button. Most calls that were answered after 10 minutes, a note was observed to be written by staff with an explanation. Not all call notifications had notes and/or reason for call. LPA Valerio reviewed Medication Administration Records (MAR) for Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), Resident 4 (R4). Medication Records for each resident showed documentation for medication refusals, medication holds, and change of medication orders. MAR documents did not show evidence of negligence and unreported medication holds or refusals for all residents.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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