507002304-12-31-2020-27-AS-KHOS-BX7MJD-20210112083855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002304
Report Date: 12/31/2020
Date Signed: 12/31/2020 04:36:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201217160112

FACILITY NAME:	HAVEN, THE		FACILITY NUMBER:	507002304
ADMINISTRATOR:	RECTO, GENOVEVA		FACILITY TYPE:	740
ADDRESS:	3636 N. VENEMAN AVENUE		TELEPHONE:	(209) 529-1533
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 4	DATE:	12/31/2020
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Linda Gacayan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not adhere to reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to deliver complaint findings 12/31/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Linda Gacayan

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, reviewed medical documents, and reviewed CCLD SIR log. LPA Martinez determined the licensee/administrator reported resident 1's health change in a timely manner to CCLD.

This agency has investigated the complaint alleging staff did not adhere to reporting requirments. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with Linda Gacayanvia via telephone and a copy of this report was provided to Linda Gacayan via email and an electronic email read receipt confirms receiving these documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/17/2020 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201217160112

FACILITY NAME:	HAVEN, THE		FACILITY NUMBER:	507002304
ADMINISTRATOR:	RECTO, GENOVEVA		FACILITY TYPE:	740
ADDRESS:	3636 N. VENEMAN AVENUE		TELEPHONE:	(209) 529-1533
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY:	6	CENSUS: 4	DATE:	12/31/2020
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Linda Gacayan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Staff did not address a change in the resident's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation on 12/31/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation with Linda Gacayan.

Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, CCLD SIR log, and resident 1's medical records. Throughout the investigation it was learned, the facility was in contact with witness 1. In addition, the facility reported resident 1's health changes to the appropriate indvidual. Furthermore, resident 1 was sent to the hospital on 2 different occasions, and on both occasions the appropriate indvidual was notifed.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20201217160112

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HAVEN, THE	FACILITY NUMBER: 507002304
	VISIT DATE: 12/31/2020

NARRATIVE

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Moreover, witness 1 reported having no concerns or complaints against the facility. Witness 1 reported the facility staff provided timely medical care to resident 1. Witness 1 reported being satisfied with the care resident 1 is receiving from the facility. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

An exit interview was conducted with Linda Gacayan. via telephone and a copy of this report was provided to Linda Gacayan via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3