507002304-1-22-2021-27-AS-KHOS-BY5JYT-20210211062829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002304
Report Date: 01/22/2021
Date Signed: 01/22/2021 06:28:51 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
01/15/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210115104726

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:	01/22/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Administrator Genoveva Recto		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not maintaining fire safety.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Tung Truong conducted a 10 -day complaint virtual visit with the facility today regarding the above allegation. LPA Truong spoke with the Administrator Genoveva Recto regarding the complaint.
The administrator advised the following. A phone line that connect to the alarm panel is bad causing the fire alarm to went off. The administrator is aware of the fire safety violations and is working on correcting the issues. The facility has scheduled with AT&T to install a new phone line by next week 1/26/2021. ADT will then open a new line and the alarm will be back to normal.

The Department was notified that the facility was not in compliance with fire safety as required based on the following:

1. Electrical: the refrigerator and freezer in the garage are plugged into the same outlet and one of the plugs is protruding exposing wires.

Continuation on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: 916-201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

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

Control Number 27-AS-20210115104726

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: 01/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

2. Exits: exits from the bedrooms must be clear all the way to the public way at the front
of the residence. there are numerous obstructions leading to the gates in the
backyard and the gate on the south side of the property opens inward and will
not completely open which does not provide clearance for a bed, gurney, or
wheelchair.
3. Alarm: proof of U.l. monitoring is required to be displayed at the fire alarm panel.
Paperwork needs to be provided.
4. Emergency lights do not activate when tested.
5. Smoke alarms are required to be interlinked and hardwired. The bedroom and
hallway smoke detectors are all required to alert when one is activated. the
current detectors are not operating properly and need to be replaced.
6. The carbon monoxide alarm is currently mounted by the kitchen and needs to be
relocated to the hallway by the bedrooms.
7. Outside: The door that separates the garage from the home needs to be self-closing and
latching
8. Storage on the back patio is not permitted. this area is an exit path and is
required to remain clear of storage.

Per licensee/administrator, they stated they have fixed the following. 1, 5, 6, 7 and 8. The licensee/administrator agreed to correct the rest by 1/26/2021.

Based on the information gathered, the allegation is substantiated.
See LIC 9099-D for deficiency cited. Appeal rights provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: 916-201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210115104726

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/25/2021 Section Cited CCR 87203	1 2 3 4 5 6 7	Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State and Fire Marshall for the protection of life and property against fire and panic.	1 2 3 4 5 6 7	The licensee/administrator agreed to fix all the violations by 1/26/2021 and will provide proof of correction statement and acknowledgement statement to LPA by 1/26/2021.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by fire violations noted on the front of the report. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	The licensee/administrator will include a statement that the facility will remain in compliance with the Fire Marshall requirements at all times.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: 916-201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3