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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005257
Report Date: 03/02/2023
Date Signed: 03/02/2023 03:49:56 PM


Document Has Been Signed on 03/02/2023 03:49 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: 23DATE:
03/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Yesenia JonesTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 3/2/2023 at 8:30am. LPA met with Adekemi Adekunle, Medication Technician/Caregiver and stated the purpose of the visit. The Caregiver contacted the Administrator(s) Brittany Yamada and Yesenia Jones regarding todays visit. The Administrator Certificate expires on 11/3/2023.

The facility is licensed for a capacity of 38 residents of which 32 may be non-ambulatory, 6 maybe bedridden and 4 may receive hospice care services. LPA and Administrator Yesenia Jones conducted a tour of the facility and observed a random amount of rooms. During this visit there is 2 persons receiving hospice services. Facility Licensing fees are current. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.5*F which is within the required range of 105-120*F. LPA observed 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. At 2:00pm, LPA reviewed 3 resident and 3 staff files. LPA interviewed the residents and staff of which the files were reviewed during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:
Designation of Facility Responsibility (LIC308), Administrator Certificate-Updated
Liability Insurance-Updated, Control of Property-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: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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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