347005239-7-17-2024-27-AS-KHOS-D83S3C-20240812133054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:49:21 PM

Unsubstantiated

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
04/09/2024 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20240409105448

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:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Food Service: Staff do not ensure that residents' dietary needs are met.

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 conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA conducted interviews with staff and residents and while there was subjective responses in terms of preferred food items and food options, LPA could not verify specific service plans related to Resident's diet and eating. LPA reviewed files and observed an assessment fron june 2023 signed by authorized representaives that the alleged victim did not need assistance with eating and was independent at that task.

Unsubstantiated

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-20240409105448

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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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Food service are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies 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 facility.

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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