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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005268
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:07:32 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:
11/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Catherine FriedlanderTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/9/21 at 10:40am to conduct a health and safety check on the residents. LPA met with Catherine Friedlander, Caregiver and stated the purpose of the visit.

LPA toured the facility to ensure there no areas that would pose a health, safety or personal rights risk to residents in care. Currently, there are 6 residents receiving care and supervision. The fire extinguishers, carbon and smoke detectors were present. LPA observed residents eating and participating in individual activities.

LPA observed 2-day perishables and 7-day non-perishables. The hot water measured at 114.5*F which is within the required range of 105-120*F. The temperature inside the facility measured at 73*F which is within the required range of 68-85*F.

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.

LPA did not observe any health and safety concerns during this visit.

As a reminder, the Change of Ownership (CHOW) Application(s) are due 11/30/21.

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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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