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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700469
Report Date: 05/05/2025
Date Signed: 05/05/2025 12:13:11 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 Cassie Yang
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: 4DATE:
05/05/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Victoria Ibezim and Gift EzeTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident is charged for services not rendered
INVESTIGATION FINDINGS:
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On May 5, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unnanounced at the facility to investigate and deliver the findings of the allegation cited above. LPA met with staff who then contacted Administrator who arrived shortly to the facility.

Today's visit, LPA conducted a file review for R1 and interview with Adminstrator to investigate the allegations citetd above.

The finding is as follow in LIC 9099-C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
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 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: 05/05/2025
NARRATIVE
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LIC 9099-C

Allegation: Resident is charged for services not rendered

The Department conducted interviews regarding the allegations cited above. The department conducted interviews regarding the allegation cited above. Interview with Administrator revealed a care conference was held to discuss R1's level of care. R1's LIC 602 indicated R1 was able to conduct self care with grooming and toileting, by based on facility observation, R1 was unable to do so. Administrator informed responsible party that one on one supervision is needed during busier hours of meal times Responsible party opted for facility to provide the additional staffing and care cost will be increased $1,200 monthly. Interview conducted with Administrator revealed that Administrator provided R1 with daily showering as R1 was unable to communicate toileting needs. Interview further revealed Administrator did not keep specific documentation of R1's one on one caregiver. File review revealed Administrator requested the additional $1,200 for the updated care cost, but was provided $500 monthly payments only.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with Administrator..
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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 Cassie Yang
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: 4DATE:
05/05/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Victoria Ibezim and Gift EzeTIME COMPLETED:
12:40 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not update the resident's admission agreement and provide a copy to the authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the finding of the allegation cited above. LPA met with Administrator and explained the purpose of the visit.

Allegation: Staff did not update the resident's admission agreement and provide a copy to the authorized representative
Based on interview and file review, it revealed R1 has one admission agreement with the facility. The following agreement was signed by R1's responsible party dated March 28, 2024. Interview conducted with Administartor revealed a care conference was held with responsible party and Sacramento County to discuss increase of level of care cost. Based on information above, the Department concluded that the allegation is unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies cited. Exit interview was conducted and a copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
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 3