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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002811
Report Date: 07/18/2023
Date Signed: 07/18/2023 05:58:25 PM


Document Has Been Signed on 07/18/2023 05:58 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CAREHAVEN VALENCIAFACILITY NUMBER:
345002811
ADMINISTRATOR:KIM, DAVIDFACILITY TYPE:
740
ADDRESS:7545 ORANGE DRIVETELEPHONE:
(916) 928-7017
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jina Kim, Co-Administrator, David Kim, Co-Administrators TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the full inspection care tool. LPA met with Jina Kim, Co-Administrator and David Kim, Co-Administrator, who arrived at the facility shortly. LPA explained the purpose of today's inspection. LPA observed (5) residents in their rooms at the start of the inspection. Currently, there are (2) resident on hospice.

LPA and Administrator toured the interior and exterior of the facility including the common areas, (4) private resident rooms, (1) shared resident room, (2) resident bathrooms, staff room, kitchen, laundry and garage. LPA observed the facility to be clean, in good repair and odor-free. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, paper towels, trash can with lid and 20-second hand-washing poster. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food in the kitchen. Sharps, toxins and medications are locked in the kitchen and additional toxins are locked in the laundry area. LPA observed sufficient PPE/incontinent supplies and linens/towels/blankets. The inside temperature measured 79*F and hot water measured 108*F in a bathroom. LPA tested (1) smoke/monoxide alarm and found it to be working. Facility conducts quarterly emergency drills. There is (1) unlocked outside gate and a covered patio dining set. LPA reviewed (3) of (5) resident files and found them to be complete with all required documentation. Medications were reviewed for (2) residents- there were no errors found and medication documentation is being done correctly. LPA reviewed (2) staff files and found them to contain current training documentation, including First Aid/CPR certification. RCFE Administrator certificates are pending renewal- documentation was sent to CCLD via certified mail on 6/15/23. LPA observed all required postings to be posted and the Emergency Disaster Plan was recently updated to reflect the purchase of a generator. Infection Control Plan is in the process of being updated. All staff are cleared and associated to the facility. An updated copy of liability insurance was obtained (exp 10/24/23). LPA requested an updated copy of LIC308 and LIC500 be faxed/emailed to the Department by 7/25/23.
There are no citations issued. Exit interview. Copy of report to be emailed to Administrators.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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