347005239-6-14-2021-27-AS-SRIN-C4C4XM-20210625192945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 06/14/2021
Date Signed: 06/14/2021 04:01:03 PM

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
12/28/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20201228091928

FACILITY NAME:	GREENHAVEN ESTATES		FACILITY NUMBER:	347005239
ADMINISTRATOR:	DONNA BAUTISTA-COLMENARES		FACILITY TYPE:	740
ADDRESS:	7548 GREENHAVEN DR		TELEPHONE:	(916) 427-8887
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	105	CENSUS: 48	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Donna Bautista-Colmenares		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff is overmedicating resident in care.

INVESTIGATION FINDINGS:

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Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion/runny nose, Nausea or vomiting, and Diarrhea. Have any individuals tested positive for COVID-19 with a laboratory confirmed test? Have any individuals been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a “No” answer to all the above-mentioned questions.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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-20201228091928

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: 06/14/2021

NARRATIVE

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/14/2021 at 3:00pm to conduct an investigation regarding the above-mentioned allegation. LPA met with Christina Luna Garcia, Business Office Manager who contacted the Administrator (ADM) Donna Bautista-Colmenares regarding the purpose of the visit. On 12/28/2020, Community Care Licensing (CCL) received a complaint. LPA opened the complaint on 12/30/2021.

LPA reviewed the centrally stored medication log for all residents residing in the memory care unit and the assisted living unit that was submitted. During the log review LPA observed there were 3 residents during the month of March 2020 receiving an anti-anxiety medication on an as needed basis (PRN). Additionally, on 6/11/2021, a review of the Medication Administration Record with Christina Luna Garcia revealed that for R1-R3 there were no medication errors documented. LPA observed that several residents have been prescribed medications that may cause drowsiness. LPA did not receive any incident reports indicating a medication error. In addition, there were no reports or incidents that were documented at the facility that residents were over medicated, or under medicated or that the medication counts were incorrect.

Based on documentation review and lack of evidence the preponderance of evidence standards has not been met.

The allegation(s) are UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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