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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005118
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:35:16 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240206125624
FACILITY NAME:HAVEN VALLEY CARE HOME #1FACILITY NUMBER:
347005118
ADMINISTRATOR:RIVERA, RENATO F.FACILITY TYPE:
735
ADDRESS:6361 LOCHINVAR WAYTELEPHONE:
(916) 873-4225
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:4CENSUS: 4DATE:
03/28/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Aurora EstacioTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff are not properly addressing pest infestation in facility
Facility staff are not ensuring that the client is siting in a comfortable position
Facility staff are not providing client with a reasonable level of privacy while using the phone
INVESTIGATION FINDINGS:
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On 3/28/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to complete and delivery findings for a complaint investigation received on 2/6/24. LPA met facility staff Aurora Estacio and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is insufficient evidence to substantiate the allegations mentioned above. Regarding the allegation facility staff are not properly addressing pest infestation in facility, LPA reviewed service records and learned that the facility has regular pest control services every two months by Terminix. Service records revealed that the facility has increased services to monthly ever since cockroaches were found.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20240206125624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #1
FACILITY NUMBER: 347005118
VISIT DATE: 03/28/2024
NARRATIVE
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Regarding the allegation facility staff are not ensuring that the client is sitting in a comfortable position, it was observed that client (R1) was sitting in a comfortable position on 2/15/24. R1 does use a neck pillow at the time of visit. It was learned that R1 is not required to have a neck pillow. According to staff interviews, staff stated that they always ensure R1 is comfortable and that the neck pillow is used interchangeably for R1’s comfort.

Regarding the allegation facility staff are not providing client with a reasonable level of privacy while using the phone, it was learned that R1 needs assistance with phone use. R1 was unable to hold the phone effectively therefore staff would put the phone on speaker. Based on staff interviews, staff stated that they would put the phone on speaker and leave R1 to talk on the phone privately; however, they would check on R1 every few minutes to see if R1 was still holding the phone properly.

As a result of the investigation, LPA finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided upon exit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2