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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003298
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:44:07 AM

Document Has Been Signed on 10/24/2022 11:44 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 AT THE MEADOWSFACILITY NUMBER:
347003298
ADMINISTRATOR:ROMAINE FELIXFACILITY TYPE:
735
ADDRESS:2158 JOHN STILL DRIVETELEPHONE:
(916) 665-2748
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY: 6CENSUS: 4DATE:
10/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ronelo Madrid, CaregiverTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a case management visit on 10/24/22 at 9am. LPA met with Ronelo Madrid, Caregiver and stated the purpose of the visit. LPA reviewed resident #1 (R1) file with Ronelo and obtained copies of the Physician Report (LIC602), Centrally Stored Medication and Destruction Record, and Special Incident report.

The investigation revealed that in reviewing documents and interviews R1 arrived as a respite to the facility with a redness on the coccyx. Although the family was aware there was no creams or orders provided to the facility. The red area became larger as confirmed by staff but there was not an open wound. The family was made aware by the Licensee of the redness. Although the resident was not seen or diagnosed by a physician, Title 22 regulations allows a stage 2 pressure injury in the home.

On the previous respite visit 1 month before, R1 sustained a bruise in the knee area. There seem to be a discrepancy on how the bruise looked but confirmed that R1 sleeps in a fetal position with knees against the wall. The family was made aware and a cushion was used to prevent any further redness or bruises on the knee. In addition, the bed was lowered for R1.

Based on the information reviewed and obtained, although the allegation may have happened or is valid,
there is not a preponderance of the evidence to prove that the alleged abuse occurred and that the facility is at fault for any deficiencies regarding Title 22 regulations.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited during this visit.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
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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