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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005268
Report Date: 10/21/2021
Date Signed: 10/21/2021 11:15:22 AM

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:HAVENWOOD RCFEFACILITY NUMBER:
347005268
ADMINISTRATOR:JEROME TECSONFACILITY TYPE:
740
ADDRESS:55 HAVENWOOD CIRCLETELEPHONE:
(916) 392-2017
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jerome TecsonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/21/21 at 9:30am. LPA was allowed entry into the home that is licensed for a capacity of 6 Non-Ambulatory residents of which 6 may receive hospice services. LPA met with Eva Dore, Caregiver and stated the purpose of the visit. LPA spoke with Jerome Tecson, Administrator regarding the purpose of the visit and the presence at the home. Administrator certificate for Jerome Tecson expires 8/19/22. LPA observed residents are present during this visit. Jerome Tecson arrived within 30 minutes to assist with todays visit. LPA obtained information from the Administrator that the Licensee passed away on 10/14/21. LPA observed the LIC308 Designation for Jerome Tecson posted during this visit. There are 0 residents receiving hospice services at this time.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2 day perishables and 7 day non-perishables.
The temperature inside the facility measured at 73 *F which is within the required range of 68-85*F. The hot water temperature was measured at 108.3*F which is within the required range of 105-120*F.

LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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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