Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005239
Report Date: 02/01/2019
Date Signed 02/01/2019 02:12:02 PM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2018 and conducted by Evaluator Laura Munoz
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20181008135607
FACILITY NAME:GREENHAVEN ESTATESFACILITY NUMBER:
347005239
ADMINISTRATOR:JUDY RODRIQUEZFACILITY TYPE:
740
ADDRESS:7548 GREENHAVEN DRTELEPHONE:
(916) 427-8887
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:105CENSUS: 58DATE:
02/01/2019
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director, Estee NowakTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff physically abused resident
INVESTIGATION FINDINGS:
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LPA Laura Munoz arrived at this facility on 02/01/19 at 9:15am to deliver findings for the allegation of physical abuse. LPA met with Executive Director, Estee Nowak and explained the purpose of today’s visit and complaint allegation.
On 09/16/18, the facility submitted an incident report to CCL stating Management at the facility learned that staff had been using a sock and/or towel and placing into R1’s mouth during assisting R1 with ADLs. R1 has a diagnosis of Dementia and a history of biting and spitting at staff. Interviews indicated it became a common practice and even a trained practice to put a sock and/or towel in R1’s mouth when she is spitting and biting. Interviews conducted indicated this practice was known and used by numerous staff for a significant amount of time, however was never reported to CCL, R1’s physical and/or R1’s family. The investigation also revealed that in 2016, staff used a pillow over R1’s mouth during changing to prevent R1 from spitting and biting staff. This incident was never reported as well. Once the facility management was made aware of the abuse, an internal investigation was conducted and numerous staff were terminated. SEE ATTACHED LIC9099
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Laura MunozTELEPHONE: (916) 709-6317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20181008135607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2019
Section Cited
CCR
87468.1(a)(3)
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87468.1(a)(3) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement as not been met as evidenced by:
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The Executive Director agrees to the following: An in-service training shall be conducted with all staff on resident rights and mandated reporting requirements. Training date shall be submitted to CCL by, 02/04/19 and proof of training shall be submitted to CCL 14 days after POC due date.
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Based on interviews and records review, the Licensee failed to ensure R1 was kept safe as well as properly train staff who put a sock/towel in R1's mouth during assisting with ADLs because of R1's spitting and biting behavior which posses an immediate health and safety risk.
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NOTE: The facility has terminated any and all staff who participate, knew about and/or trained in a putting a sock and/or towel in R1’s mouth.
Type A
02/04/2019
Section Cited
CCR
87463(a)
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87463(a) Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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The Executive Director agrees to the following: A plan shall be submitted to CCL stating how the facility will reappraise residents who exhibit combative behavior. Plan shall include how resident's rights are to be maintained. Plan shall be submitted by POC date, 02/04/19
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This requirement has not been met as evidenced by: Based on interviews and record reviews, the Licensee failed to reappraise R1 once staff observed R1 was combative (spitting and biting) when staff assisted R1 with ADLs which posses an immediate health and safety risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Laura MunozTELEPHONE: (916) 709-6317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20181008135607
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: GREENHAVEN ESTATES
FACILITY NUMBER: 347005239
VISIT DATE: 02/01/2019
NARRATIVE
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At this time, any and all staff who participate, knew about and/or trained in a putting a sock and/or towel in R1’s mouth are no longer employed at the facility.

Not only was facility staff physically abusing R1 by putting a foreign object in her mouth, the facility failed to conduct a reappraisal of R1 to develop a plan on how to handle R1's combative behaviors.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22 citations are being cited on the attached LIC9099D.

Exit Interview and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Laura MunozTELEPHONE: (916) 709-6317
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2019
LIC9099 (FAS) - (06/04)
Page: 3 of 3