Greenhaven Estates, a 740‑type group home in Sacramento, was the subject of four unannounced case‑management visits during early 2021. The first visit on February 24 2021 was a tele‑visit conducted to verify compliance with the facility’s probationary license (June 18 2020–June 18 2023). The licensing program analyst (LPA) observed adequate temperature control, safe hot‑water levels, properly stored medications, and a compliant first‑aid kit, finding no deficiencies. A second, same‑day visit delivered an immediate exclusion order to staff member S‑1, though the exclusion was not linked to Greenhaven and did not reflect a lapse in resident care.

The third visit, on March 27 2021, arose from a complaint investigation and uncovered a serious deficiency: staff member S‑1 had been eating residents’ food during meals, jeopardizing residents’ nutritional needs and posing a health‑and‑safety risk. The LPA cited a single deficiency under Title 22, requiring a plan of correction due April 26 2021 and the possibility of civil penalties if uncorrected. The facility acknowledged the deficiency and received its rights information, while the LPA reminded the administrator to submit a staffing plan if a shortage existed and to maintain posted stipulations.

The final visit on April 6 2021 again focused on probationary compliance. The LPA reviewed the physical plant, staff schedules, and operational equipment, noting that knives were inaccessible and that the facility met all safety and medication storage requirements. No new deficiencies were cited. Across all visits, Greenhaven Estates demonstrated overall adherence to regulatory standards, with the sole outstanding issue being the staff‑related feeding violation addressed through immediate exclusion and a corrective plan. The pattern suggests a facility that generally meets safety and care expectations but must resolve the isolated lapse in resident nutrition practices.