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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 10/17/2024
Date Signed: 10/31/2024 02:55:45 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
06/17/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240617115702
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: 47DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Latrice RossTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Neglect/lack of supervision: Resident sustained injury while in care.
Physical Plant: Staff did not ensure that resident's room was free of hazards.

Qualifications: Staff are not properly trained.
Physical Plant: Resident's air conditioner is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to Greenhaven Estates RCFE on 10/17/24 at 1:30pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with appointed administrator Latrice Ross and together discussed the investigation details.

Based on the interviews, statements and records obtained during the investigation process, the allegations are substantiated. LPA confirmed resident was injured by tools that vendors were using to repair an air conditioner in the resident's room that had not been working for 18 days. This was confirmed by staff statements and LPA observations of photos provided to LPA. The resident was allowed access to the room when vendors and tools were present in the resident's room. As a result, the resident was sustained an injury to their foot/toe that required medical intervention.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 27-AS-20240617115702
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: 10/17/2024
NARRATIVE
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LPA reviewed file for responding staff member and did not observe sufficient training to meet regulations of 20 hours of annual training, of which 8 should be dedicated dementia care. LPA observed only two hours of training in 2024 related to dementia and the initial training observed also did not meet regulations. LPA was also unable to review a first aid certificate for the responding staff member.

Additionally, LPA has determined through communications with the reporting party and facility staff members the air conditioner was not operational from May 10, 2024 until it was repaired by an contracted vendor on 5/29/24. As the facility may have taken steeps to repair the A/C unit by facility maintenance staff, the initial contact with the contracted vendor as provided to LPA was 5/22/24 12 days after fist being reported.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of neglect/lack of supervision, physical plant and qualifications is substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22. As the injury to the resident was sustained as a result of a deficiency observed during the investigation, an immediate civil penalty is issued and may be evaluated for additional penalties by the department..

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-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
06/17/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240617115702

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: 47DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Latrice RossTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Other: Staff did not issue proper refund.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Greenhaven Estates RCFE on 10/17/24 at 1:30pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with appointed administrator, Latrice Ross and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the allegations cannot be substantiated. At the time of the complaint, The resident's representatives and facility were negotiating a refund for dates the resident was not living at the facility due to the residents air conditioner not working in the resident's room. As the room was still being rented by the resident and their belongings were still present in the resident's unit, the conditions for a refund were not met under title 22 regulations as the resident is not deceased and had not removed items from the unit prior to the complaint being received by the department.
Report Continued on LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240617115702
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: 10/17/2024
NARRATIVE
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The Department has investigated the complaint alleging Other. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff and a copy of this 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: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240617115702
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
87303(a)
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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:
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Facility has agreed to provide a written plan of correction on the steps facility will take to ensure resident safety when contracted vendors are present in a residents room preforming repairs.
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 resident sustained an injury as a result of vendors tools being accessible to resident who tripped on the tools resulting in an injury to their foot/toe that required medical attention which poses an immediate health, safety or personal rights risk to residents in care.
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Type A
10/18/2024
Section Cited
CCR
87464(f)(1)
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Basic Services: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by resident's sustained injury as a result of being allowed access to a room where repairs are ongoing
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Facility has agreed to provide a written plan of correction on the steps facility will take to ensure resident safety when contracted vendors are present in a residents room preforming repairs.
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which poses an immediate health, safety and personal rights 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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240617115702
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2024
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evicenced by confirmation the AC unit was not working and the earliest documentation of
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Facility has agreed to provide a written plan of correction on the procedures for facility repair including in house and contracted repairs and the timelines and responsibilities for each.
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attempted repair from a contracted vendor provided to LPA was 12 days after it was first reported to the facility which poses a potential health, safety and personal rights risk to residents in care.
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Type B
10/18/2024
Section Cited
HSC
1569.625(b)(2)
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Staff training; legislative findings; contents: In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall
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Facility will submit a written plan of correction of their intention to audit each staff file and will submit the results of their findings by 10/31/24.
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be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6