347005239-4-24-2025-27-AS-KHOS-DGUJ8W-20250520065011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 04/24/2025
Date Signed: 04/24/2025 03:44:24 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
01/03/2025 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20250103145745

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	LATRICE ROSS		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 57	DATE:	04/24/2025
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Alexandria Noel		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Questionable Death: Staff did not administer resident's medication resulting in death

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Greenhaven Estates RCFE on 4/24/25 at 1:20pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Alexandria Noel 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. Per the police report, they have identified R1 as having passed away from natural causes. Staff and resident interviewed confirmed medication administration was delayed for R1 as the facility med tech called out at the last minute and the facility already had another staff member capable of administering medications en route when R1's partner alerted staff to R1 being unresponsive. Per interviews LPA could not confirm R1 was still alive at the time medications should have been passed. Staff interviews were inconsistent and the only resident who approached staff members was R1's partner.

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: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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-20250103145745

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: 04/24/2025

NARRATIVE

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The staff member (S1) who responded and provided CPR to R1 provided statements that R1 was already cool to touch and had no pulse when they arrived to respond to R1's medical emergency. R1's partner, R2, does not believe R1's death was a result of any delay in medication administration. Local police have determined R1 passed of natural causes and is not investigating.

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 Questionable Death 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: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC9099 (FAS) - (06/04)

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