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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003494
Report Date: 02/25/2025
Date Signed: 02/25/2025 02:20:25 PM

Document Has Been Signed on 02/25/2025 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GREEN FIELD HAVENFACILITY NUMBER:
347003494
ADMINISTRATOR/
DIRECTOR:		KONONOV, LARISAFACILITY TYPE:
740
ADDRESS:3620 WINONA WAYTELEPHONE:
(916) 482-1314
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY: 6CENSUS: 6DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On February 25, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the inspection tool. LPA met with caregiver who then contacted Administrator who arrived to the facility shortly afterwards.

LPA observed posted license to be outdated. LPA printed a new facility license to post. LPA observed the posted Administrator Certificate to be expired but file review reveals Administrator Certificate is active on CCLD website. LPA will reach out to Admin Cert unit for a copy to provide to Administrator.

LPA observed the resident roster to be present. LPA observed six residents to be residing in the "South" part of the facility. In the "North" part of the facility, LPA observed three tenants name listed.

LPA and Administrator conducted a tour of the North and South of the facility. Areas toured included but not limited to: North bedrooms, bathroom, and common areas. South bedrooms, laundry room, bathroom, kitchen and the common areas.

Administrator and LPA discussed facility's current hospice waiver of two. Administrator stated she was informed her license was approved for four. LPA will provide Administrator a copy of CCR 87632 Hospice Care Waiver. Additionally, LPA and Administrator discussed the pending fingerprint clearance for T1.

LPA informed Administrator, LPA will return a later date to complete this annual inspection.

At this time, LPA obtained a copy of staff schedule and facility liability insurance.

Exit interview and a copy of report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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