Inspection Reports for Greenhaven Estates

An unannounced case management deficiencies inspection was conducted to address observations of the facility.

The inspection found that the dining room floor was dirty, sticky, and had observable grime and dirt, indicating it was not regularly cleaned. A Type B deficiency was cited for failure to maintain the facility clean, safe, sanitary, and in good repair.

The visit was a case management inspection to discuss the status of the appointment of a new administrator and to remind staff of regulatory requirements regarding administrator certification and notification.

The licensing program analyst met with the interim administrator to review the status of the new administrator's certification application, which was received and is in process of approval. The department outlined required documentation for approval of a new administrator.

An unannounced complaint investigation was conducted in response to allegations that staff hit and threatened a resident.

The investigation found no corroboration of the allegations after interviews with the resident, their authorized representative, staff, and other residents. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint involved allegations of staff hitting and threatening a resident. The allegations were unsubstantiated based on interviews and lack of evidence.

The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

The facility was generally clean, odor-free, and in good repair with proper furniture and lighting. However, three outdoor maintenance storage areas were unsecured, and staff files lacked verification of required annual training including dementia care training.

An unannounced complaint investigation was conducted in response to an allegation that staff did not administer a resident's medication resulting in death.

The investigation found insufficient evidence to corroborate the allegation. The resident was determined to have died of natural causes, and no deficiencies were cited.

The allegation of questionable death due to medication non-administration was unsubstantiated based on interviews, police report, and investigation findings.

An unannounced complaint investigation was conducted in response to an allegation that staff did not ensure an adequate temperature was maintained in the facility for residents in care.

The investigation found that the facility maintained temperatures above the minimum requirement of 68 degrees F, with hallways and dining rooms set at 73 degrees F. Interviews with residents were mixed, but overall the allegation was unsubstantiated and no deficiencies were cited.

The complaint was unsubstantiated based on interviews and observations. Although some residents felt the temperature was too cold, the evidence did not support the allegation. No deficiencies were cited per California Code of Regulations, TITLE 22.

An unannounced complaint investigation was conducted in response to allegations regarding physical plant issues including disrepair of facility doors, heater malfunction, inappropriate removal of garbage bins, and restricted access to the smoking area.

The investigation found no substantiation for the allegations. The door to the smoking area had a malfunctioning electronic assist device in the process of being replaced, the heater was functioning properly, and no evidence was found of improper garbage removal. No deficiencies were cited.

The complaint was unsubstantiated based on interviews and observations. The department determined there was insufficient evidence to prove the alleged violations occurred.

An unannounced plan of correction (POC) inspection was conducted to ensure previously cited deficiencies have been corrected as agreed upon by the department and facility representatives.

All previously cited deficiencies were corrected and the facility was found to be in compliance with title 22 regulations. No deficiencies were observed or cited during this inspection.

An unannounced complaint investigation was conducted in response to allegations received on 2024-06-24 regarding lack of supervision, disrespect of residents' personal rights, and failure of overnight staff to perform required checks and services.

Based on interviews with staff and residents, the allegations were found to be unsubstantiated. No deficiencies were cited under California Code of Regulations, TITLE 22. The facility demonstrated ongoing efforts to manage resident supervision and care.

The complaint included allegations of lack of supervision resulting in residents disturbing others, residents' personal rights not being respected, and overnight staff not performing required checks and services. The investigation found no preponderance of evidence to substantiate these allegations.

The inspection was conducted as an unannounced complaint investigation following allegations received on 2024-08-20 regarding resident bathing and staff response to call lights.

The investigation found one allegation unsubstantiated regarding resident bathing per service agreement, and one allegation substantiated regarding staff delays in responding to call lights. The substantiated allegation resulted in a cited deficiency related to failure to provide timely assistance to residents.

The complaint investigation was triggered by allegations that a resident was not bathed per service agreement and that staff were not responding to call lights in a timely manner. The bathing allegation was unsubstantiated, while the call light response allegation was substantiated.

An unannounced complaint investigation was conducted based on allegations received on 06/17/2024 regarding neglect/lack of supervision, physical plant hazards, staff qualifications, and air conditioner disrepair at Greenhaven Estates facility.

The investigation substantiated allegations that a resident was injured by tools used by vendors repairing a non-functional air conditioner in the resident's room, which had been out of service for 18 days. Staff training was insufficient, and the air conditioner repair was delayed. Another complaint regarding improper refund issuance was found to be unfounded.

The complaint investigation was substantiated for neglect/lack of supervision, physical plant hazards, and staff qualifications. The allegation regarding improper refund issuance was unfounded.

An unannounced complaint investigation was conducted due to an allegation that a resident did not have hot water in their unit.

The investigation substantiated the complaint, finding that hot water temperatures throughout the facility were below Title 22 regulations, posing a potential health, safety, and personal rights risk to residents.

The complaint was substantiated based on the preponderance of evidence obtained during the investigation regarding the physical plant issue of inadequate hot water temperature.

An unannounced complaint investigation was conducted in response to allegations of neglect/lack of supervision due to staff not responding to resident pendant calls and physical plant issues related to the facility elevator being in disrepair.

The investigation substantiated the allegations that staff delays in responding to call pendants resulted in residents waiting for care, sometimes soiling themselves, and that the elevator was shut down in March 2024 due to delayed repairs of the elevator phone system. Deficiencies were cited related to medical and dental care and maintenance and operation of the facility.

The complaint investigation was substantiated based on interviews with staff, residents, and a family member, confirming delays in call response times and elevator disrepair issues.

An unannounced complaint investigation was conducted in response to allegations of neglect and lack of supervision, specifically regarding unmet incontinence needs, delayed response to call buttons, and insufficient staffing to meet resident needs.

The investigation substantiated the allegations based on interviews with staff, residents, and a family member, confirming delays in call response times, residents soiling themselves while waiting for assistance, and insufficient staffing levels to meet resident needs. Deficiencies were cited related to medical and dental care arrangements and personnel requirements.

The complaint investigation was substantiated. Allegations included neglect and lack of supervision, specifically unmet incontinence needs, delayed call button responses, and insufficient staffing. Interviews with five staff members, four residents, and a family member supported these findings.

An unannounced complaint investigation was conducted in response to allegations that staff did not ensure residents' dietary needs were met.

The investigation was unable to corroborate the allegations. Interviews and file reviews indicated that the alleged resident was independent in eating and no specific service plans related to diet and eating were found. The complaint was determined to be unsubstantiated.

The complaint was unsubstantiated based on the investigation. There were no deficiencies cited per California Code of Regulations, TITLE 22.

An unannounced Plan of Correction (POC) inspection was conducted to ensure that past deficiencies cited have been corrected.

The inspection found that while most issues such as light fixtures were corrected, the kitchen storage closet door remained unlocked with sharp knives accessible to residents, posing an immediate health and safety risk. Due to this being the second violation within 12 months, an immediate civil penalty was issued.

The inspection was conducted as a continuation of the required one-year annual inspection begun on 2024-05-24.

No deficiencies were cited during the inspection. Most resident files were complete except one requiring an updated LIC 602 form which was over a year old and needed renewal.

The inspection was conducted as a required 1 year annual inspection to evaluate the facility's compliance with health and safety regulations.

The facility was generally clean and in good repair, but several deficiencies were noted including unsecured cleaning supplies and sharp objects accessible to residents, missing health screenings and certifications in staff files, improper glove disposal, non-slip mats missing in memory care showers, and several lights out in common areas.

The inspection was conducted on 04/11/2024 during an unrelated complaint investigation to assess compliance with food service temperature regulations.

The licensing program analyst observed refrigerator temperatures and logs showing temperatures exceeding the maximum allowed 40 degrees Fahrenheit, with some readings as high as 45 degrees, posing a potential health, safety, and personal rights risk to residents.

The visit was conducted while investigating an unrelated complaint. Specific substantiation status is not stated.

An unannounced case management inspection was conducted to gather additional information regarding control of property and change of administrator.

The Licensing Program Analyst met with the executive director and confirmed the submission of requested documents to confirm the appointment of a new administrator. An exit interview was conducted and a copy of the report was left at the facility.

An unannounced case management inspection was conducted to gather additional information regarding control of property and facility name change.

The Licensing Program Analyst met with the executive director to discuss recent changes at the facility, transition to a new management group, and provided required documents for a name change. Plans were made to submit control of property information and name change request documents to the department by 2/16/24.

An unannounced case management visit was conducted to address concerns regarding facility change of ownership and to ensure the health and safety of residents in care.

The visit found that the facility had changed its business signage and a new management company was added to the license without notification to the Department. Deficiencies were cited related to failure to notify the department of the sale of the property and loss of control of the property, posing immediate health, safety, and personal rights risks to residents.

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that facility staff did not ensure that residents are provided care in a timely manner.

The investigation found that although there were staff call outs, additional staff were available to assist with resident care needs. Based on interviews and observation, the allegation was deemed unfounded and no deficiencies were observed or cited.

The complaint was that facility staff did not ensure timely care for residents. The allegation was found to be unfounded, meaning it was false or without reasonable basis, and the complaint was dismissed.

This is a case management visit regarding an incident report received at Community Care Licensing involving Resident #1 who was missing from the facility for approximately 2 hours without staff knowledge.

The investigation revealed that Resident #1 was AWOL from the facility for about 2 hours due to the exit door alarm being turned off during maintenance, posing an immediate health and safety risk to residents. Staff failed to ensure the facility was secure and safe.

The visit was triggered by a complaint incident report regarding Resident #1 being returned by police after being missing from the facility for approximately 2 hours. The preponderance of evidence standard was met.

The visit was an unannounced case management inspection focused on deficiencies, including a review of administrator changes and compliance with licensing requirements.

The inspection found that the facility lacked a qualified and currently certified administrator or a designated substitute on file with the Community Care Licensing, posing an immediate health and safety risk to residents.

The inspection was conducted to investigate complaints alleging staff stealing a resident's money, staff being rough with a resident, and staff neglect resulting in a resident fall.

The investigation found no preponderance of evidence to support the allegations. The complaint was deemed unfounded, meaning the allegations were false or without reasonable basis, and no deficiencies were cited.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Victoria Brown. Interviews with staff, residents, and review of documentation led to the conclusion that the allegations were unfounded and the complaint was dismissed.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including night shift staff sleeping, staff handling residents roughly causing bruising, inappropriate use of children to care for residents, maintenance of expired medications, medication accessibility to residents, and questionable death.

The allegation of night shift staff sleeping was substantiated based on a photo and interviews, posing an immediate health and safety risk. Other allegations including rough handling causing bruising, use of children to care for residents, maintenance of expired medications, and medication accessibility were unsubstantiated due to lack of preponderance of evidence. The allegation of questionable death was unfounded as it was investigated under a different complaint and dismissed.

The complaint investigation was substantiated for the allegation of night shift staff sleeping, meaning the allegation was valid based on the preponderance of evidence. Other allegations were unsubstantiated or unfounded. The substantiated allegation required a plan of correction with an estimated completion of 90 days.

An unannounced complaint investigation was conducted following a complaint received on 2023-06-29 alleging that staff did not seek timely medical attention for a resident.

The investigation found that the resident was sent to the hospital twice for swallowing and breathing issues, with staff providing appropriate care and assistance. The allegation was deemed unfounded with no violations cited during the visit.

The complaint alleged that staff did not seek timely medical attention for a resident. After investigation, the allegation was found to be unfounded, meaning it was false or without reasonable basis.

The visit was conducted to obtain information regarding an Incident Report about a medication error involving a resident receiving a double dose of medication.

The investigation confirmed that a medication error occurred where a resident received a double dose in the morning and was not provided medical attention despite reporting feeling unwell. Staff involved were interviewed, and corrective actions including termination and in-service training were taken.

The visit was complaint-related due to a medication error incident report. The preponderance of evidence standard was met confirming the medication error and lack of medical attention.

The visit was an unannounced Case Management visit conducted by Licensing Program Analyst Victoria Brown to address the immediate exclusion order for staff member S1.

No deficiencies were observed or cited during the visit. The facility was informed and agreed that staff member S1 is immediately excluded from employment or presence on the premises.

An unannounced complaint investigation was conducted due to an allegation that staff do not respond to residents’ call buttons in a timely manner.

The investigation found that the allegation was unfounded, meaning it was false or without reasonable basis. No deficiencies were observed or cited during the visit.

The complaint was related to staff response time to call buttons. Interviews and observations revealed residents were unhappy about staff layoffs but there was no care or supervision issue. The allegation was deemed unfounded.

The visit was conducted to ensure there is an Administrator on file with the Department following the departure of the previous Administrator and to review related documentation.

The Licensing Program Analyst found that required documentation for the designee and new Administrator was incomplete, unsigned, and not submitted in a timely manner. The facility roster was not updated to reflect the current Administrator. A deficiency was cited related to Administrator qualifications and duties.

An unannounced complaint investigation was conducted due to an allegation that staff did not provide a refund to the responsible party.

The investigation found that a refund of $6,760.13 was owed due to a mistake on a ledger and had not yet been issued but would be sent out from the corporate office. The allegation was substantiated based on evidence and admissions from facility representatives.

The complaint was substantiated. The allegation was that staff did not provide a refund to the responsible party. The refund amount was $6,760.13 and had not been issued at the time of the investigation but was to be sent via certified mail.

The visit was an unannounced case management follow-up to review two incident reports involving missing money and missing credit cards reported in October 2022.

No deficiencies were cited during the visit. The Licensing Program Analyst reviewed the facility's theft and loss procedures and requested copies of police reports related to the incidents.

Unannounced complaint investigation visit conducted due to multiple allegations received on 2023-02-16 regarding resident care, safety, staffing, and facility conditions at Greenhaven Estates.

The complaint was found to be unfounded after investigation, with no deficiencies observed. The allegations were determined to be false or without reasonable basis, and the complaint was dismissed.

The complaint included multiple allegations such as failure to follow resident's prescribed diet, mold in resident rooms, inadequate staffing, lack of training for resident transfers, delayed response to call pendents, failure to ensure resident safety resulting in injuries, failure to notify POA of hospitalization, false statements, unsafe resident rooms with tripping hazards, electrical issues, failure to report incidents to CCL, unexplained rent increases, failure to notify POA and resident of probationary license, and failure to provide fire drill instructions. All allegations were found to be unfounded.

The visit was an unannounced case management follow-up to an incident report regarding a resident finding a thumb tack in a bowl of fruit.

The facility was cited for a violation of food service requirements after a resident was served food that was not safe for consumption, posing an immediate health and safety risk. The investigation found thumb tacks used in the kitchen area where food was served.

The inspection was an unannounced Required - 1 Year visit to evaluate the facility's compliance with licensing regulations.

No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including safety, medication storage, and environmental conditions.

The visit was an unannounced Case Management visit to ensure that the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.

No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including staff training, medication audits, safety inspections, and environmental conditions.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-01-30 regarding multiple allegations including incontinent needs not being met, call lights not being answered timely, staff disrespectfulness, and unmet medical needs.

The investigation substantiated the allegations that incontinent care was delayed causing urinary accidents, call lights were not answered timely, staff were disrespectful to residents, and medical needs were not properly met due to lack of authorization for PRN treatments. The Administrator was aware and took action by terminating two staff members.

The complaint investigation was substantiated based on interviews with residents and staff, review of medical and service plans, and observation of facility practices. The preponderance of evidence standard was met for all allegations.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-06-01 regarding a resident with an unknown wound on the back and the facility retaining a resident beyond their level of care.

The investigation substantiated that a resident had a stage 3 pressure injury on the back that progressed while in the facility, and the facility retained the resident beyond their licensed level of care for about one month. Another allegation that the facility admitted a resident outside the scope of care and that a resident had to be fed all meals was found to be unsubstantiated.

The complaint investigation was substantiated for two allegations: a resident had an unknown wound on the back that progressed to a stage 3 pressure injury, and the facility retained a resident beyond their level of care for approximately one month. The other allegations regarding admission of a resident outside the scope of care and feeding needs were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-06-02 regarding allegations including a resident sustaining a pressure injury while in care.

The investigation substantiated that residents R1, R5, and R6 sustained pressure injuries while in care, including a level 3 pressure injury for R1. Other allegations regarding medication administration, forced bed exit, diabetic care, and repositioning were found to be unsubstantiated based on interviews, observations, and medical record reviews.

The complaint investigation was substantiated for the allegation that a resident sustained a pressure injury while in care. Other allegations including medication not administered as prescribed, staff forcing resident to get out of bed, diabetic care needs not met, and resident not being rotated and repositioned were unsubstantiated.

The visit was conducted to investigate an incident of theft involving two residents on 10/20/22, as reported in an Incident Report submitted to Community Care Licensing on 10/25/22.

The investigation found insufficient evidence to substantiate the theft allegations. Interviews with staff and residents' responsible parties revealed no unusual charges or confirmed missing money, and no violations were cited during the visit.

The complaint involved alleged theft of money from two residents. The allegation was not substantiated due to lack of evidence and failure to meet the preponderance of evidence standard.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-08-17 regarding allegations that staff did not receive training on the memory care (MC) and assisted living (AL) units, and that residents did not receive food.

The investigation found that staff had received training on both the MC and AL units, and residents were provided food as meals were always offered either in the dining hall or in their rooms. Interviews with staff, residents, and a family member supported these findings. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint investigation was unsubstantiated as there was no preponderance of evidence to prove the allegations that staff were not trained or residents did not receive food. Staff interviews, resident and family member statements indicated training and meal provision were adequate.

The visit was an unannounced Case Management visit focused on legal and non-compliance issues at the facility.

No deficiencies were observed or cited during the visit. The facility met all regulatory requirements including proper food storage, temperature controls, safety equipment, and medication storage.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2022-09-12 alleging rough handling and yelling at a resident by staff.

The investigation found no substantiation of the allegations due to lack of evidence and recantation by the resident. No personal rights violations or deficiencies were cited.

The complaint involved allegations that staff handled a resident in a rough manner and yelled at the resident. The resident initially reported being pushed and yelled at by staff but later recanted. The complaint was found to be unsubstantiated.

The visit was an unannounced health and safety check conducted by the Licensing Program Analyst to evaluate the facility's compliance with cleanliness and safety regulations.

The inspection found that 4 out of 5 resident rooms were clean and free of debris; however, Resident 1's bathroom had black mold along the floor tiles, which posed a potential health and safety risk. The facility was cited for failing to maintain the bathroom in a clean, sanitary, and odorless condition.

The visit was an unannounced Case Management - Legal/Non-compliance inspection conducted to evaluate the facility's compliance with regulations.

No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including proper food storage, adequate staffing, environmental conditions, and safety equipment.

An unannounced complaint investigation visit was conducted following a complaint received on 2022-08-05 regarding multiple allegations about resident supervision, staff treatment, documentation, notification, and confidentiality at Greenhaven Estates.

The investigation substantiated that a resident was not adequately supervised to prevent entering other residents' rooms, citing a deficiency related to residents' personal rights. Other allegations including staff disrespect, failure to document health changes, failure to notify authorized persons, and disclosure of confidential information were found unsubstantiated or unfounded.

The complaint investigation was substantiated for the allegation that a resident was not adequately supervised to prevent entering other residents' rooms. Other allegations were unsubstantiated or unfounded. The substantiated deficiency was cited under CCR 87468.2(a)(1) with a plan of correction due by 2022-09-09.

An unannounced annual inspection was conducted to evaluate compliance with licensing regulations and facility standards.

The inspection found unlocked toxins in the memory care common area posing an immediate health and safety risk. Other areas such as physical plant, medication storage, food supplies, fire safety, and staff clearances were found compliant.

The visit was an unannounced Case Management visit to ensure there is an Administrator in place as per Title 22 regulations and the Stipulation.

No deficiencies were cited during this visit. The Licensing Program Analyst was presented with all required documents to change the Administrator in the Community Care Licensing system.

The visit was an office touch-base conference call requested by the licensee to discuss and review procedures put in place to ensure the facility remains in substantial compliance following a prior Non-Compliance Conference.

No deficiencies were cited during this visit. The facility discussed updates on administrator change, technical support, medication training/errors, staffing, and reporting requirements. The facility committed to several actions to maintain compliance, and the Department will increase monitoring and re-evaluate compliance before any legal action.

The visit was an Office type Non-Compliance Conference conducted to discuss the high volume of complaints, deficiencies cited, and inability to remain in substantial compliance with regulations or specific incidents occurring in the last 24 months.

The facility was cited with 21 Type A citations and 7 Type B citations along with civil penalties from 8/31/2020 to present, involving issues such as Covid-19 response, personnel requirements, personal rights, reporting, and other regulatory areas. No deficiencies were cited during this specific visit.

The visit was conducted as a Case Management follow-up to review additional items observed during a complaint investigation on 12/3/2021.

The investigation found that resident #1 (R1) was sent out to pick up insulin without supervision, which violated regulations as R1 was deemed unable to leave the facility unassisted. The administrator failed to provide adequate supervision, posing an immediate risk to residents.

The visit was triggered by a complaint investigation regarding resident #1 being sent out unsupervised to pick up medication, which was substantiated based on interviews and documentation.

The visit was an unannounced Case Management visit focused on legal and non-compliance issues conducted by Licensing Program Analysts.

No deficiencies were cited during this visit. The facility was observed to be in compliance with regulations including physical plant conditions, safety equipment, and resident care activities.

The visit was a Case Management visit conducted due to notice that the Administrator Donna Bautista-Colmenares was no longer working at the facility, and to verify the interim designation of responsibility.

No deficiencies were cited during this unannounced Case Management visit. The Licensing Program Analysts observed the designation of responsibility posted and reviewed the current Administrator Certificate.

The inspection was an unannounced complaint investigation visit triggered by allegations including a resident missing medications and illegal eviction due to not providing a 30 day supply of medication prior to admittance.

The investigation substantiated that a resident missed a dose of insulin due to medication not being timely provided and that the resident was evicted without the required 30 day written notice for not having a 30 day supply of medication upon admittance. The facility failed to provide proper eviction notice and timely refrigerated medication, posing immediate risk to residents.

The complaint investigation was substantiated based on the preponderance of evidence standard. Allegations included missed medications and illegal eviction due to lack of medication supply. The resident missed a dose of insulin and was evicted without proper notice. The facility was cited for deficiencies related to eviction procedures and medication management.

The visit was an unannounced Case Management visit focused on Legal/Non-compliance issues.

The Licensing Program Analyst toured the facility including Assisted Living and Memory Care sides, observed compliance with first aid kits, fire extinguishers, alarm systems, and food supplies. No deficiencies were cited during this visit.

The visit was an unannounced subsequent complaint investigation related to alleged deficiencies, including unauthorized release of resident photos and failure to timely report hospitalization and COVID-19 positive cases.

The investigation found that the facility did not obtain permission to publish photos of residents R1 and R2, failed to timely submit an incident report for hospitalization of resident R5, and did not include R5 on the required Public Health COVID-19 line list. Additionally, the administrator provided false information regarding the identity of a resident in a Facebook video.

The visit was triggered by a complaint investigation (27-AS-20211029101055) concerning unauthorized photo release and reporting failures. The complaint was substantiated by findings of unauthorized photo release, late incident reporting, and false information provided by the administrator.

An unannounced complaint investigation was conducted due to an allegation that facility staff were not wearing masks.

The investigation substantiated the allegation that staff were not wearing masks and not social distancing inside the facility, based on interviews, video, and photos. One staff member (S1), identified as an infection control lead, was observed not following infection control practices, posing an immediate health and safety risk to residents.

The complaint allegation that facility staff were not wearing masks was substantiated based on the preponderance of evidence including interviews, video, and photos.

The visit was an unannounced Case Management - Health Checks inspection to conduct a health and safety check on the residents and observe procedures put in place following a Health Care Associated Infections (HAI) visit on 10/13/2021.

The Licensing Program Analyst observed discrepancies in medication management including mismatched room numbers on pill containers, unlabeled medication cups, missing pills from bubble packs, and staff's inability to explain medication systems. Additionally, staff lacked knowledge of the LIC308 Designation of Responsibility form, and required signage and hand sanitizer were not posted in designated areas.

An office meeting was conducted to discuss recommendations from the Health Care Associated Infections (HAI) to ensure the facility remains in substantial compliance with infection control, specifically to mitigate the spread of Covid-19.

No deficiencies were cited during this visit. The meeting recapped recommendations from CDPH's Covid-19 Outbreak Facility Assessment Tool and reviewed the facility's implementation of these recommendations, including infection control leads and daily reporting commitments.

This visit was conducted to amend the Case Management visit citation from the previous Case Management visit made on 2021-07-21, related to an incident involving medication administration errors.

The report cites a Type B deficiency due to a medication error where Resident #1 received Tramadol twice in one day during medication training, and the narcotics count was off. It was determined that the resident was not in immediate health and safety risk at the time.

The visit was an unannounced Case Management visit to review a random amount of resident files, including annual assessments and physician reports.

No deficiencies were cited during this visit. Six of the seven resident Physician Reports were updated within the year 2021, with one exception for a resident who left prior to the annual due date.

The visit was an unannounced complaint investigation to cite deficiencies observed during the complaint investigation and file review at Greenhaven Estates.

The investigation found that the facility failed to provide requested admission agreements, removed wheels from a resident's chair without approval or documentation, and did not ensure the resident was checked every 1-2 hours as required by the Interim Service Plan, posing immediate health and safety risks.

The complaint investigation was triggered by concerns including failure to provide admission agreements and unsafe removal of chair wheels for a fall-risk resident. The preponderance of evidence standard was met.

The visit was an unannounced complaint investigation conducted to deliver findings related to allegations that staff failed to provide timely medical attention after a resident fall and failed to supervise a resident which resulted in death.

The investigation substantiated that staff failed to provide medical attention in a timely manner after Resident #1 fell multiple times in 2020 and did not transport the resident to the hospital despite known head trauma. The facility also failed to move the resident to the memory care unit after decline. Another allegation that staff failed to supervise the resident resulting in death was unsubstantiated due to lack of evidence.

The complaint investigation was substantiated for the allegation that staff failed to provide timely medical attention after a resident fall. The allegation that staff failed to supervise the resident resulting in death was unsubstantiated.

The visit was conducted as a Case Management investigation following an incident report of a missing narcotic medication from a resident's medication supply.

The investigation found that a narcotic medication was missing from Resident #1's supply, staff involved were drug tested with negative results except one staff member who left early and was scheduled for termination. The facility failed to document notification of the physician and responsible parties, and staff left without proper termination documentation, posing immediate health and safety risks.

The visit was complaint-related due to an incident report of a missing narcotic medication. The preponderance of evidence standard was not met to substantiate staff wrongdoing, but deficiencies were cited related to notification failures and staff termination procedures.

The visit was an unannounced Case Management inspection triggered by an incident report regarding missing and tampered medications involving Hydrocodone at the facility.

The investigation found that prescribed medications were missing and replaced with unknown pills, posing an immediate health and safety risk. Drug tests on staff were negative, and corrective actions including staff removal from medication duties and hiring a replacement were underway. The preponderance of evidence standard was not met to substantiate exploitation.

The visit was complaint-related due to an incident report of medication tampering involving missing Hydrocodone tablets replaced with unknown pills. Drug testing of staff was negative except one staff member who failed to appear for work and was being terminated. The preponderance of evidence standard was not met.

The visit was a Case Management - Other type of unannounced inspection to evaluate the facility.

This report amends a previous case management report dated 7/21/21, correcting the visit date. No other findings or deficiencies are detailed in this report.

The visit was a Case Management - Other type of unannounced visit to the facility.

This report amends a previous case management report dated 7/21/21 due to an incorrect visit date being input. The licensing program analyst will assess civil penalties for the repeat violation.

Unannounced complaint investigation visit conducted due to an allegation that a resident was admitted to the hospital with an opiate overdose.

The allegation was substantiated based on documentation and interviews revealing multiple incidents of medication errors and drug delivery to a resident despite a plan to prevent it. The facility failed to effectively follow protocols to ensure resident safety, with a history of overdosing residents from 2020 to date.

Complaint was substantiated. The allegation involved a resident admitted to the hospital with an opiate overdose. The investigation found multiple medication errors and failure to follow safety protocols. The preponderance of evidence standard was met.

The visit was an unannounced Case Management inspection conducted due to an incident report indicating that a resident took medication twice in one day.

The facility failed to assist a resident with medication administration as required by the physician's report, resulting in the resident taking medication twice in one day. This posed an immediate health and safety risk to residents in care.

The visit was triggered by a complaint/incident report regarding Resident #1 taking medication twice in one day. The deficiency was substantiated as the facility did not provide assistance as required.

The visit was an unannounced Case Management inspection conducted to investigate an incident report regarding a medication error involving Resident #1 receiving Tramadol twice in one day and discrepancies in the narcotics count.

The inspection found a medication error during medication training where a resident received the same medication twice, and the facility failed to ensure proper medication procedures were followed, posing an immediate health and safety risk to residents.

The visit was an unannounced Case Management inspection conducted due to an incident report received regarding a medication error involving Resident #1 on 05/26/2021.

The facility was found to have a deficiency for administering incorrect medication to a resident, posing an immediate health and safety risk. The incident report was incomplete and the facility self-reported the incident, leading to citation of the deficiency.

The visit was triggered by a complaint/incident report indicating that Resident #1 received incorrect medication on 05/26/2021, which resulted in decreased pulse and activation of 911. The incident report was incomplete and lacked medication details.

The visit was an unannounced Case Management - Incident investigation conducted to follow up on medication error incident reports received for several dates in 2020 and 2021.

The Licensing Program Analyst attempted to conduct interviews and requested additional documentation related to medication errors occurring on multiple dates. The occurrences require further investigation.

The visit was triggered by incident reports indicating medication errors on 7/14/2020, 8/25/2020, 9/25/2020, 9/26/2020, and 5/26/2021. Further investigation is needed.

The Licensing Program Analyst conducted an unannounced Required - Annual visit to evaluate the facility's compliance with regulations and ensure safety and proper care.

No deficiencies were observed or cited during the inspection. The facility met all regulatory requirements including safety systems, medication storage, and environmental conditions.

An unannounced complaint investigation was conducted regarding an allegation that staff were overmedicating a resident in care.

The investigation found no evidence of medication errors or overmedication. Medication logs and administration records were reviewed, and no incidents or reports of medication errors were documented. The complaint was unsubstantiated.

The complaint alleged that staff were overmedicating a resident. The investigation was unsubstantiated based on lack of evidence and documentation review.

An unannounced complaint investigation visit was conducted in response to allegations that staff did not administer residents' medication in a timely manner and did not answer residents' call buttons promptly.

The investigation found no preponderance of evidence to substantiate the allegations. Medication Administration Records and call button response times were reviewed and showed no evidence of negligence or unreported issues. Staffing coverage was adequate, and no deficiencies were cited.

The complaint was unsubstantiated due to lack of sufficient evidence to prove the alleged violations occurred. The investigation included interviews with administrators and staff, review of medical and facility records, and attempted resident interviews which were unsuccessful.

Unannounced complaint investigation visit conducted to investigate multiple allegations including inappropriate restraint use, inadequate food service, medication administration delays, unclean facility conditions, bad odor from dog feces, and failure to provide resident activities.

Based on interviews with staff and lack of evidence, all allegations were found to be unsubstantiated. The facility was reported to be clean, residents received timely medication and adequate food, and activities were provided. No deficiencies were cited during this visit.

The complaint investigation was unsubstantiated. Allegations included inappropriate restraint use, inadequate food service, medication administration delays, unclean facility, bad odor from dog feces, and failure to provide activities. Interviews with staff and review of evidence did not support the allegations.

The visit was an unannounced tele-visit conducted due to COVID-19 and precautionary measures to ensure the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.

No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including safety, medication storage, first aid kit contents, and resident and staff file requirements.

The inspection visit was an unannounced complaint investigation triggered by an allegation received on 06/15/2020 that staff handled a resident in a rough manner causing bruises.

The investigation substantiated the allegation that staff member S13 grabbed Resident #1's wrists causing bruises. The licensee failed to ensure the resident was kept free from abuse, posing an immediate health and safety risk. Employment of S13 was suspended and terminated, and the plan of correction was cleared prior to the visit.

The complaint was substantiated based on interviews and evidence. Staff member S13 confirmed yelling and grabbing R1's wrists. The preponderance of evidence standard was met and the allegation was substantiated.

This Case Management visit was conducted as a result of a deficiency noted during a complaint investigation, specifically related to COVID-19 precautionary measures and resident care.

The licensing analyst confirmed through interviews that a staff member was eating food off residents' plates during meal times, resulting in residents not receiving the quantity of food necessary to meet their nutritional needs, posing a potential health and safety risk.

Visit was complaint-related; deficiency noted during complaint investigation. Substantiation status not explicitly stated.

The visit was an unannounced tele-visit conducted due to COVID-19 precautionary measures to ensure the care home is meeting the terms and conditions of its probationary license effective from 6/18/2020 to 6/18/2023.

No deficiencies were observed or cited during the visit. The facility was found to be in compliance with regulations including medication security, first aid kit contents, safety hazards, and environmental conditions.

The visit was a case management visit conducted to deliver an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility.

The Licensing Program Analysts delivered exclusion orders to the facility administrator and staff, requiring the excluded staff member to leave the facility immediately. The exclusion was not related to this facility.