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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002304
Report Date: 12/10/2021
Date Signed: 12/10/2021 12:26:26 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
12/03/2021 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20211203132937
FACILITY NAME:HAVEN, THEFACILITY NUMBER:
507002304
ADMINISTRATOR:RECTO, GENOVEVAFACILITY TYPE:
740
ADDRESS:3636 N. VENEMAN AVENUETELEPHONE:
(209) 529-1533
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY:6CENSUS: 5DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Genoveva RectoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff member did not follow reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johnson made a complaint investigation visit to open the complaint and deliver findings.

Allegation: Facility staff member did not follow reporting requirements.

Based on interview with Administrator on 12/10/2021, the facility did not report the incident with R1. The incident was relayed to Valley Mountain Regional center SC that R1 has been banging her head on the floor for 6 hours. SC asked Linda to provide an SIR since this is a self-injury. The Administrator stated "No, that R1 was new to the facility and was not sure of the targeted behaviors and was accessing R1 for service plan needs."

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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-20211203132937
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: 12/10/2021
NARRATIVE
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As a result of information obtained and the interview conducted the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6.

Exit interview with Administrator

Appeals rights printed.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211203132937
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: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2021
Section Cited
CCR
80061(b)(1)
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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Licensee will submit a plan to ensure timely reporting of incidents to licensing department. Plan shall include a procedure for designating an individual in charge of auditing and ensuring
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 Based on record review licensee did not ensure timley reporting of the incident for R1.

This poses a potential health and safety risk for resident in care
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accurate and timely reporting. Licensee to submit plan to LPA by POC due date.
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3