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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003494
Report Date: 04/08/2026
Date Signed: 04/08/2026 12:05:07 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
12/31/2025 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 59-AS-20251231114722
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:
04/08/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Larisa KononovTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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1 Staff did not keep the facility free from infestation
2. Staff mishandled a resident's medication
3. Staff did not meet a resident's oxygen needs
4. Staff did not timely address a resident's change in medical condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hiratsuka, conducted this unannounced visit to deliver the findings for the allegations above.

1. LPA interviewed staff and residents. Licensee stated when the weather was hot there was an issue with roaches coming into the facility. Licensee stated she put out traps and that stopped the roaches from coming into the facility. LPA was informed there was an issue with the toilet in one of the bathrooms and a few roaches were found until the toilet was fixed and that was only one time. The person stated the toilet was fixed quickly. LPA did not observe any roaches, rodents, or bugs in the facility during today's visit and on 03/11/2026. LPA cannot confirm or deny the facility was infested based on the above and observations.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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-20251231114722
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: 04/08/2026
NARRATIVE
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2. The medication in question regards blood pressure and blood pressure medications. License stated the resident moved in with very little medication. Witness stated the blood pressure reading indicated the blood pressure medications were not given correctly. Staff stated they don't remember being told the blood pressure was too low. Staff stated they give the medication as prescribed. LPA is not able confirm or deny based on each side having their own version of events.

3 and 4. Licensee stated the resident moved in with oxygen equipment but no doctor's orders. Licensee stated the resident also refused to use the oxygen. Physician's report states resident is unable to self administer oxygen but there is no order in the paperwork stating the resident requires oxygen. LPA interviewed the resident and the resident stated they never needed oxygen. Witness stated the resident's oxygen levels were very low and the resident showed signs of distress. Licensee has since contacted the doctor and received confirmation the oxygen is not needed. LPA cannot confirm or deny the allegation based on the above.


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.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2