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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700469
Report Date: 08/01/2024
Date Signed: 12/03/2024 04:32:38 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240610101925
FACILITY NAME:GREAT HAVENFACILITY NUMBER:
342700469
ADMINISTRATOR:EZE, CHINYEREFACILITY TYPE:
740
ADDRESS:71 GROTH CIRTELEPHONE:
(916) 833-6388
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:6CENSUS: 3DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Chinyere, Eze, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not keep facility at a comfortable temperature
INVESTIGATION FINDINGS:
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AMEND to change findings and make Public- On August 1, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-20240610101925. LPA met with Chinyere Eze, Licensee, and informed her the reason for the visit.

During the investigation, LPA conducted interviews with staff and residents, and conducted file reviews and room inspections. Results of the investigation are as follows:

Allegation: Staff do not keep facility at a comfortable temperature
The Department conducted interviews regarding the allegation cited above. LPA interviewed staff and residents. The interviews of 3 staff and 1 resident revealed staff conducts daily checks-in on residents to ensure room are at a comfortable temperature. During LPA’s inspection, the facility was at a comfortable temperature.UNSUBSTANTIATED.









Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 4
Control Number 59-AS-20240610101925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREAT HAVEN
FACILITY NUMBER: 342700469
VISIT DATE: 08/01/2024
NARRATIVE
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SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240610101925

FACILITY NAME:GREAT HAVENFACILITY NUMBER:
342700469
ADMINISTRATOR:EZE, CHINYEREFACILITY TYPE:
740
ADDRESS:71 GROTH CIRTELEPHONE:
(916) 833-6388
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY:6CENSUS: DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
11:56 AM
MET WITH:Chinyere, Eze, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not update the resident's care plan and provide a copy to the authorized representative
INVESTIGATION FINDINGS:
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On August 1, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-20240610101925. LPA met with Chinyere Eze, Licensee, and informed her the reason for the visit.
Allegation: Staff did not update the resident's care plan and provide a copy to the authorized representative.
The Department conducted interviews regarding the allegations cited above. Interviews with licensee indicated upon R1’s admission, the licensee completed an initial needs and service plan and sent a copy of R1’s responsible party. Licensee stated that based on further assessment of R1, it was observed that R1’s needs are beyond what the facility can provide. Based on Title 22, 87456 (in part), “prior” to accepting a resident for care, the facility shall perform a pre-admission appraisal. If a pre-appraisal was conducted prior to R1’s moving into the facility, the licensee would have been aware that R1’s needs were higher than that of what the licensee could provide. SUBSTANTIATED....
To continue nsee 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20240610101925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GREAT HAVEN
FACILITY NUMBER: 342700469
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2024
Section Cited
CCR
87463(b)
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87463(b) Reappraisal-The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person.
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 The licensee shall update and submit a new needs and service plan for R1. Needs and Service plan shall articulate R1’s current needs and how the facility will meet those

Client is no longer at facility.
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This requirement is not met as evidence by, based on LPAs review of documentation, the licensee did not ensure the Reappraisal was updated and complete, and sent to the responsible party, which poses an potential Health and Safety risk to residents in care. If the Rappraisal was conducted the licensee would have been aware that R1’s needs were higher level of care than that of what the licensee could provide.
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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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4