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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003494
Report Date: 10/14/2025
Date Signed: 10/14/2025 03:30:28 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
09/19/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250919154608
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: 5DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lena GubinaTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed several UTI's while in care due to staff neglect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the finding of the allegation above. LPA met with Caregiver and explained the purpose of the visit.
For the allegation of, Resident developed several UTI's while in care due to staff neglect, based on an interview conducted with the Administrator, it was revealed that only one resident (R1) in care has had a recent urinary tract infection. The interview revealed that R1 was admitted to the facility with a catheter and has home health coming to the facility twice a week. The facility assists with catheter draining but is unable and not trained to clean the urinary tube. An interview conducted with the caregiver revealed that the caregiver assists with draining R1’s catheter bag as needed. R1 often tugs and pulls on the catheter, and once disconnected, then home health is contacted for the tube to be reinserted. Based on the information provided, the allegation is unsubstantiated.
As a result of this investigation, LPA finds the 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 no preponderance of evidence to prove that the alleged violation occurred.
Exit interview and a copy of report was provided.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 2
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
09/19/2025 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 59-AS-20250919154608

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: 5DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lena GubinaTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that resident's incontinence needs are being met while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst (LPA) Cassie Yang arrived at the facility to deliver the finding of the allegation above. LPA met with Caregiver and explained the purpose of the visit.
For the allegation of, Staff do not ensure that resident's incontinence needs are being met while in care. The Department conducted extensive interviews for the allegation above. An interview conducted with R1 revealed R1 does get assistance whenever needed. R1 emphasizes the satisfaction of the care staff and feels safe living at the facility. Interview conducted with R2 revealed that R2 feels comfortable at the facility and gets assistance with changing and toileting. R2 denied any lack of care and supervision. Interview conducted with R3 revealed that the care at the facility is “excellent” and that they receive full assistance with activities of daily living. Interview conducted with R4 revealed that R4 does not need assistance with incontinence care, but has not witnessed any staff avoiding care for other residents in care. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
An exit interview was conducted, and a copy of the report was provided.
Unfounded
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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 2