507002304-7-1-2021-27-AS-KHOS-C4NLBB-20210706083627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002304
Report Date: 07/01/2021
Date Signed: 07/01/2021 01:23:58 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
04/29/2021 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20210429093707

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: 2	DATE:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Administrator Genoveva Recto		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility is in disrepair, no hot water

INVESTIGATION FINDINGS:

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On 07/01/2021 at 12:30 PM, Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a complaint investigation and deliver findings. LPA Valerio introduced herself, explained the purposed of the visit, and was met by Administrator Genoveva Recto and Licensee Linda Gacayan. LPA Valerio was screened for COVID-19 symptoms and temperature was taken prior to being allowed entry into the facility.

Complaint investigation composed of resident interviews, staff interviews, observation, and record review.

On 07/01/2021, LPA Valerio interviewed residents and staff. LPA Valerio tried to interview R1; however, the interview was deemed unsuccessful due to the resident's cognitive state. LPA Valerio could not interview R2 due to R2 being out on a visit.

Continued on LIC-9099 C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210429093707

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: 07/01/2021

NARRATIVE

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On 07/01/21, LPA Valerio interviewed staff. S1 stated that "residents have not told me the water is not hot. We have hot water here." S1 has been working at the facility since May 2021 as a Day Shift Caregiver.

Administrator and Licensee informed LPA Valerio R2 does say the water does not get hot enough. Administrator stated that R2 does not know how to turn the hot water knob. R2 wants to shower alone and does not want assistance. Administrator has tried to show R2 how to turn the knob. Administrator states that R2's service coordinator has been informed about not knowing how to turn the knob and the service coordinator is aware of the situation.

LPA Valerio reviewed last annual inspection conducted by LPA Brown on 06/09/2021. LPA Brown and LPA Hurt observed the water temperature to be 105*F.

LPA Valerio took the hot water temperature in the resident bathroom. Hot water temperature was observed to be 105.4*F. LPA Valerio observed the hot water temperature in the kitchen to be 106.7*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

The investigation concluded, based on interviews, inspections and record review that the allegations are 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 evidence to prove that the alleged violations occurred. Based on LPA’s observations and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are determined to be UNSUBSTANTIATED.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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