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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700667
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:21:19 PM

Document Has Been Signed on 12/19/2024 03:21 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:HAVEN VALLEY CARE HOME #2FACILITY NUMBER:
342700667
ADMINISTRATOR/
DIRECTOR:		RIVERA, RENATO F.FACILITY TYPE:
735
ADDRESS:6023 FIELD BROOK CTTELEPHONE:
(916) 873-4225
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
12/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Romaine FelixTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Romaine Felix and explained the purpose of the visit.

LPA Moleski conducted an annual inspection of this facility on 12/10/24. During this visit, LPA Moleski observed a resident (R1) in a wheelchair with a seatbelt buckled across their waist. LPA Moleski asked R1 to unbuckle the belt. R1 was able to unbuckle the belt within a few seconds. LPA Moleski spoke with facility administrator Renato Rivera during that visit and explained that R1 would need a physician's order on file for the use of such a postural support. Rivera said that R1 did have a doctor's order, but he would need to locate it. LPA Moleski asked for Rivera to email him a copy when he found it. Rivera emailed LPA Moleski on 12/11/24, but did not provide any doctor's order. On 12/12/24, LPA Moleski reminded Rivera via email that he needed R1's doctor's order for the postural support. To this date, 12/19/24, LPA Moleski has not received any such doctor's order for the use of a wheelchair belt.

Additionally, during that same annual inspection on 12/10/24, LPA Moleski observed that a staff member (S1) had a first aid/CPR certificate which expired on 1/7/24. Rivera told LPA Moleski that S1 had an updated first aid/CPR certificate. LPA Moleski asked Rivera to email LPA Moleski the certificate. Rivera emailed LPA Molesk a first aid/CPR certificate for S1 on 12/11/24, which listed a completion date of 12/11/24.

This facility is being cited per 22 CCR Sections 80072(a)(8)(B) and 80075(f) An exit interview was held with Felix. Appeal rights and a copy of this report was left with Felix.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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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Document Has Been Signed on 12/19/2024 03:21 PM - It Cannot Be Edited


Created By: Vincent Moleski On 12/19/2024 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HAVEN VALLEY CARE HOME #2
FACILITY NUMBER: 342700667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
Section Cited
CCR
80072(a)(8)(B)

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"(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order."
This requirement was not met as evidenced by:
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Licensee agrees to send physician's order for the support by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation and record review, no physician's order was maintained in R1's record for the use of a wheelchair seatbelt, which poses an immediate health, safety, and/or personal rights risk.
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Type B
01/09/2025
Section Cited
CCR80075(f)

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" (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross." This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding recertification requirements by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview, S1 did not have a current first aid/CPR certification between January and December 2024, which poses a potential health, safety, and/or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
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