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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003494
Report Date: 10/01/2024
Date Signed: 10/29/2024 03:45:51 PM

Unfounded


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
08/02/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240802154406
FACILITY NAME:GREEN FIELD HAVENFACILITY NUMBER:
347003494
ADMINISTRATOR:KONONOV, LARISAFACILITY TYPE:
740
ADDRESS:3620 WINONA WAYTELEPHONE:
(916) 482-1314
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 3DATE:
10/01/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Larisa Kononov, LicenseeTIME COMPLETED:
09:31 AM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs.
Staff are not allowing resident to use the phone
INVESTIGATION FINDINGS:
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Amend: To make Public- On October 1, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for complaint #59-AS-20240802154406. LPA met with Larisa Kononov, Licensee, and informed her the reason for the visit.

The Department received a complaint alleging staff are not meeting resident’s hygiene needs and staff are not allowing resident to use the phone.

LPA interviewed all staff (3) and 2 witnesses and a resident. LPA reviewed medical documents of the resident and facility files. According to all staff, Resident #1 (R1) is incontinent. LPA verified R1’s condition with the physician’s report. The Licensee states R1 receives 2 to 3 showers a day due to R1’s medical condition. R1 told LPA, R1 doesn’t want to visit with their family. R1 stated the facility is talking good care of him and gets showers and shaves daily. R1 also said when their family comes to visit, R1 doesn’t make eye contact or speak with their family. ALLEGATION UFOUNDED.

To continue see 9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 2
Control Number 59-AS-20240802154406
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: GREEN FIELD HAVEN
FACILITY NUMBER: 347003494
VISIT DATE: 10/01/2024
NARRATIVE
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9099-C...
Regarding the allegation that staff will not allow resident to use the phone, in an interview, R1 indicated was making calls in the middle of the night so their family took R1's cell phone and R1 agreed. ALLEGATION UNFOUNDED.

This agency has investigated the complaint alleging staff are not meeting resident’s hygiene needs and staff are not allowing resident to use the phone, based on LPA's observations and interviews the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

Per California Code of Regulations, Title 22, no citations were issued.

An exit interview was conducted and a copy was given to Larisa.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2