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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700667
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:31:52 AM

Document Has Been Signed on 10/24/2022 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HAVEN VALLEY CARE HOME #2FACILITY NUMBER:
342700667
ADMINISTRATOR:RIVERA, RENATO F.FACILITY TYPE:
735
ADDRESS:6023 FIELD BROOK CTTELEPHONE:
(916) 873-4225
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Renato Rivera - AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA was allowed entry into the home that will be licensed for a capacity of 4 of which 2 maybe non ambulatory and 1 may be bedridden. LPA met with administrator and explained purpose of visit. Administrator certificate expires .

LPA and administrator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 112.5*F is within the required range of 105-120*F. The temperature inside the facility measured at 73.6*F which is within the required range of 68-85*F.
LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked. LPA observed the fire extinguisher(s) were inspected , smoke and carbon monoxide detector(s) in the home. Facility has central heating and air.

LPA reviewed 2 Staff and 2 Resident files that were locked and readily available for review. Staff had current First Aid/CPR certificates. All staff have pasted criminal records background and are cleared to work in facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held with administrator and a copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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