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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005257
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:37:13 PM


Document Has Been Signed on 03/02/2022 12:37 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:ACC ASSISTED LIVING AT GREENHAVEN TERRACEFACILITY NUMBER:
347005257
ADMINISTRATOR:YESENIA JONESFACILITY TYPE:
740
ADDRESS:1180 CORPORATE WAYTELEPHONE:
(916) 394-6399
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:38CENSUS: 19DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Yesenia JonesTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required – 1 Year inspection on 3/2/22 at 11:30am. LPA met with Yesenia Jones, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 38 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed that all meals are picked up from ACC Care Center and transported in hot boxes and warmers are used to keep them at the correct temperature for serving. The facility has a hospice waiver for 4 and there are 2 residents receiving hospice care services at this time.

LPA observed adequate supply of 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 107.4*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Upon a file review the following items were discussed to be submitted with any changes annually:
Application (LIC200), Designation of Facility Responsibility (LIC308)
Liability Insurance, Personnel Report (LIC500), Administrator Certificate-Updated

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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