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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005239
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:25:17 PM

Document Has Been Signed on 12/14/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:BENJI DOCTOLEROFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 105CENSUS: 49DATE:
12/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Adriana Vue (LVN) Interim Assisted Living Director (ALD)TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/14/23 at 9am on a subsequent visit. LPA met with Adriana Vue (LVN) Interim Assisted Living Director (ALD) and stated the purpose of the visit.
This is a case management visit regarding an incident report received at Community Care Licensing (CCL).

LPA reviewed the incident report which indicated that Resident #1 (R1) was returned to the facility by the police. R1 was observed at Starbucks around approximately between 5-7am on 9/12/23. R1 did not sustain any injuries during this incident.

LPA obtained information that the facility was having maintenance performed at which time the alarm on the exit door was possibly turned off.

Based on review of SIR and interviews the investigation revealed that R1 was missing from the facility for approximately 2 hours without staff knowledge. The door was not checked after the work was completed for that day to ensure the auditory alarms were functioning properly. Staff did not assure facility was secure and safe for residents in care.

The preponderance of evidence standards has been met.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/14/2023 04:25 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/14/2023 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2023
Section Cited
CCR
87705(6)

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Care of Persons with Dementia
Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents if they wander away from the facility.
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Licensee/Administrator shall submit a plan to conduct a documented in-service on safety measures for both Memory Care and Assisted Living residents. The plan is to be faxed to CCL by POC due date.
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This requirement is not met as evidenced by: Based on observation and interviews which confirmed R1 Awol'd from facility and was gone for approximately 2hrs.
This violation poses an immediate health, and safety risk to residents in care.
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 Additionally, a copy of the in-service to include signatures, date, time, length, presenter name, title shall be faxed to CCL by POC due date of 12/22/23.
Type A
12/15/2023
Section Cited
CCR87705(j)

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Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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Licensee/Administrator shall ensure all exit alarms are functioning properly. Confirmation in writing shall be faxed to CCL by POC due date.
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This requirement is not met as evidenced by: Based on observation and interviews which confirmed the alarms were not working during the time R1 eloped from the facility.
This violation poses an immediate health, and safety 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:Stephen Richardson
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023


LIC809 (FAS) - (06/04)
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