Inspection Reports for Greenhaven Place

An unannounced Case Management deficiencies inspection was conducted to address concerns regarding an incident report dated 10/24/25 related to reported medication violations.

The inspection found that a staff member (S1) documented administering a narcotic medication to a resident who was not present at the time, and the staff member was under the influence of a narcotic during medication administration. The facility administrator suspended the staff member pending investigation, and law enforcement and the resident's family were notified.

The visit was complaint-related based on an incident report alleging medication violations involving unaccounted narcotics and staff impairment. The complaint is substantiated by written statements and investigation findings.

The inspection was conducted as a required 1 year annual inspection of Greenhaven Place Assisted Living to evaluate compliance with health and safety regulations.

The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. Water temperatures were measured and found within acceptable ranges, food supplies were sufficient, and fire safety equipment was current and compliant. No deficiencies were cited during the inspection.

The inspection was a required 1 year annual unannounced inspection conducted to evaluate the health and safety conditions of the facility.

The facility was found to be clean, odor-free, and in good repair with all required furniture and sufficient lighting. No deficiencies were cited during the inspection.

The visit was conducted as an unannounced investigation of a medication error reported in an Unusual Incident/Injury Report dated 9/15/23 involving resident #1 (R1).

The investigation confirmed that on 9/12/23, R1 received medication at the wrong time and missed eye drops during the 2pm medication pass due to staff inadvertently switching medications and times. No adverse reactions occurred. Staff member responsible was removed from the Medication Technician position and will be re-trained.

The complaint investigation was substantiated based on the preponderance of evidence from documents and interviews regarding the medication error involving resident #1.

The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2023-04-27 regarding resident care, notification failures, staffing, safety, and facility management at Greenhaven Place Independent Living and Assisted Living.

The investigation substantiated two allegations: the facility did not follow a resident's prescribed diet and failed to notify the resident's power of attorney (POA) of hospitalization. Other allegations related to staffing, call pendant response, resident safety, false statements, rent increase notification, fire drill instructions, physical plant issues, staff training, and incident reporting were found unsubstantiated or unfounded.

The complaint investigation was substantiated for allegations that the facility did not follow the resident's prescribed diet and failed to notify the resident's POA of hospitalization. Other allegations were unsubstantiated or unfounded. The substantiation was based on interviews, record reviews, and incident reports.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-05-12 regarding retaliation against a resident for filing a previous complaint, inappropriate touching by staff, and unclean resident bathroom and kitchen.

The investigation included interviews, record reviews, and observations. All allegations were found to be unsubstantiated or unfounded based on lack of evidence and observations. No evidence of retaliation or inappropriate touching was found, and the resident's bathroom and kitchen were observed to be clean.

The complaint investigation was unsubstantiated. Allegations included retaliation against a resident for filing a previous complaint and staff touching a resident inappropriately. After interviews with staff and residents, review of personnel files, and observation, the allegations were not supported by evidence. Additionally, the allegation that the resident's bathroom and kitchen were dirty was found to be unfounded.

The visit was an unannounced case management inspection to obtain additional information regarding a Special Incident Report about a medication error where resident #1 received resident #2's medication.

The investigation confirmed the medication error occurred with no adverse reaction. A deficiency was cited for failure to designate an employee responsible for assisting residents with self-administration of medications, posing a potential health and safety risk.

The visit was triggered by a complaint via a Special Incident Report (SIR-LIC624) received on 08/28/2023 regarding a medication error where resident #1 received resident #2's medication. The preponderance of evidence standard was met confirming the complaint.

The visit was an unannounced Required - 1 Year inspection conducted to evaluate the facility's compliance with regulations and ensure safety for residents.

The Licensing Program Analyst toured and inspected the facility, observed residents, and verified safety measures including temperature controls, fire safety equipment, and medication storage. No deficiencies were cited during this inspection.

The visit was an unannounced Case Management visit triggered by an incident report received on 2022-03-31 regarding a resident's allegation that a caregiver was verbally aggressive while assisting with care needs.

The investigation found that the caregiver in question resigned after being pulled from the floor and there was insufficient evidence to prove the alleged abuse occurred. No deficiencies were cited during this visit.

The complaint involved an allegation of verbal aggression by a caregiver. The caregiver did not confirm or deny the behavior but admitted to frustration. The caregiver resigned and the facility was found not at fault with no deficiencies cited.

The visit was conducted as a Case Management visit following an incident report received on 3/25/2022 alleging physical abuse by a caregiver.

The investigation found no preponderance of evidence to prove the alleged abuse occurred or that the facility was at fault. No deficiencies were cited during this visit.

The complaint involved an allegation of physical abuse by a caregiver reported by a resident. The resident refused to be interviewed and stated the incident happened under different management about a year ago. The allegation was not substantiated.

The visit was an unannounced case management incident investigation regarding a car accident involving Resident #1 (R1) that occurred on or about 09/15/2022.

The investigation revealed that Resident #1 was driving alone and had a car accident with no major injuries. The facility did not ensure supervision as required by the resident's physician report and preplacement appraisal, posing an immediate health and safety risk.

The visit was triggered by an incident report submitted to Community Care Licensing regarding Resident #1's car accident. The complaint investigation found that the facility failed to provide required supervision to the resident, substantiating the complaint.

Unannounced case management visit to evaluate deficiencies related to the facility's administration and management, specifically regarding the absence of a qualified and certified administrator and lack of a Designation of Facility Responsibility (LIC308).

The facility lacked a qualified and currently certified administrator, with no LIC308 designation posted or available, and no administrator hired or present on premises. Staff were unsure about the designation form, posing an immediate health and safety risk to residents.

The visit was an unannounced case management incident investigation regarding an incident report submitted about Resident #1 (R1). The Licensing Program Analyst conducted interviews and reviewed documentation related to concerns about R1's safety and financial charges.

The investigation found that the facility did not violate any Title 22 regulations and is collaborating with Adult Protective Services, the Primary Care Physician, and Law Enforcement to ensure R1's physical and monetary safety. No deficiencies were cited.

The visit was triggered by a complaint involving concerns about unauthorized charges on Resident #1's bank card and the resident's confusion and safety. The complaint was investigated and found unsubstantiated with no regulatory violations.

The visit was a required unannounced annual inspection conducted to evaluate the facility's compliance with regulations and ensure safety for residents.

The inspection found no deficiencies. The facility met all regulatory requirements including safety hazards, temperature controls, medication storage, and emergency supplies.

The visit was an unannounced complaint investigation conducted in response to allegations received on 09/13/2021 regarding staff intimidation of residents, inadequate food service, and failure to conduct required fire drills.

The investigation found all allegations to be unfounded after interviews, observations, and document reviews. Staff were not intimidating residents, food service was adequate with balanced menus overseen by a dietician, and required fire drills and trainings were conducted and documented.

The complaint included allegations of staff intimidating residents, inadequate food service, and failure to conduct fire drills. The investigation concluded these allegations were unfounded based on interviews with residents, staff, and administrators, as well as review of documentation and observations.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 04/26/2021 regarding staff mishandling medication, failure to prevent a resident from wandering, and failure to properly report an incident involving a resident.

The investigation substantiated all allegations: staff mishandled medication by failing to administer prescribed medications timely; staff failed to prevent a resident from wandering and eloping from the facility; and staff did not properly report incidents or provide requested documentation to the resident's representative. These deficiencies posed immediate health and safety risks.

The complaint investigation was substantiated. Allegations included mishandling of medication, failure to prevent resident wandering, and failure to properly report incidents. The resident was diagnosed with Mild Cognitive Impairment and Parkinson's disease, and eloped from the facility on 4/12/21. Documentation and incident reports confirmed the allegations.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff mismanaged a resident's medication.

The investigation substantiated the allegation that a medication error occurred when a resident missed a dose of insulin due to the staff being unable to locate the medication. The Administrator and Nurse had previously submitted an incident report and conducted in-service training. The deficiency posed an immediate health and safety risk to residents.

The complaint allegation that staff mismanaged a resident's medication was substantiated based on interviews and documentation review. The preponderance of evidence standard was met.

The visit was a required, unannounced annual inspection conducted to evaluate compliance with licensing regulations and ensure resident safety and well-being.

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 visit was conducted in response to multiple allegations received on 01/11/2021 regarding facility cleanliness, maintenance, resident activities, transportation, and visitation policies.

All allegations were investigated and deemed unsubstantiated. Observations confirmed that trash was properly managed despite staff shortages, the handicap button was functional though some repairs were pending, activities were provided according to schedule, transportation was limited due to COVID-19 guidelines, and visitation restrictions had been lifted with appropriate communication.

The complaint investigation was unsubstantiated. Allegations included failure to keep the facility free of trash, disrepair of the handicap button, lack of resident activities, failure to provide transportation as agreed, and prohibition of resident visits. All were found unsubstantiated after inspection and review of documentation.

The inspection visit was conducted to investigate a complaint alleging that staff failed to safeguard a resident's financial property resulting in grand theft.

The complaint was substantiated based on interviews and a police report indicating that Staff #1 misappropriated over $14,000 from Resident #1's finances. The Administrator allowed Staff #1 access to the resident's personal finances, posing an immediate health and safety risk.

The complaint was substantiated. Staff failed to safeguard a resident's financial property resulting in grand theft. Evidence included interviews and a Sacramento Police Report confirming misappropriation of over $14,000 by Staff #1.

An unannounced complaint investigation visit was conducted due to allegations received on 2021-01-07 concerning resident neglect, unmet needs, lack of family contact assistance, unclean resident room, and missing belongings.

The investigation found no substantiated evidence to support the allegations. Interviews and observations indicated that resident needs were met, rooms were cleaned regularly, and missing items were either recovered or unconfirmed. The complaint was determined to be unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated based on interviews, observations, and review of evidence. Allegations included resident decline due to neglect, unmet needs, lack of assistance with family contact, unclean room, and missing belongings. No deficiencies were cited.

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 staff requiring immediate removal from the facility. One staff member was excluded as a result, but this exclusion was not related to the facility itself.