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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700667
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:52:35 AM

Document Has Been Signed on 01/09/2024 11:52 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jolly PapaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit regarding an incident report. LPA Moleski spoke with facility administrator Renato Rivera over the phone and explained the purpose of the visit. Rivera said staff could sign this report in his absence.

The incident report described a resident's (R1's) hospitalization on 12/30/23. LPA Moleski interviewed Rivera, reviewed R1's hospital discharge notes, and reviewed R1's file.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with staff member Jolly Papa.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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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