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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002304
Report Date: 12/22/2021
Date Signed: 12/29/2021 10:47:43 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
12/20/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211220100932
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:
12/22/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Linda GacayanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Medications are accessible to the residents in care.
Hazards are accessible to residents in care.
Facility staff are not adhering to COVID-19 mask protocol.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 12/22/2021 at 9:30 a.m. to investigate the above allegations. LPA met with Administrator Linda Gacayan and explained the purpose of today’s visit.

Regarding the allegation medications are accessible to the residents in care. Based on records reviewed, and Valley Mountain Regional Center (VMRC) Staff observations during an unannounced visit on 12/17/2021 the facility has medications that are accessible to residents in care. LPA reviewed documents from the unannounced visit conducted that states VMRC staff observed Licensee’s medication in a kitchen drawer unlocked. As a result of information obtained 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.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 4
Control Number 27-AS-20211220100932
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: 12/22/2021
NARRATIVE
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Regarding the allegation hazards are accessible to residents in care. Based on records reviewed and Valley Mountain Regional Center (VMRC) staff observations from an unannounced visit to the facility on 12/17/2021 the licensee had cleaning supplies in the kitchen and bathroom unlocked. LPA reviewed documents from the recent unannounced facility that documented VMRC staff observed cleaning supplies unlocked in the kitchen and bathroom. As a result of information obtained 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.

Regarding the allegation facility staff are not adhering to COVID-19 mask protocol. Based records reviewed, LPA observation and Valley Mountain Regional Center (VMRC) staff observation during an unannounced visit to the facility on 12/17/2021 the facility staff is not wearing masks inside the facility. LPA reviewed documents from the unannounced visit on 12/17/2021 by VMRC that stated no staff was wearing masks in the facility during the visit. LPA also observed during the visit on 12/22/2021 no facility staff wearing masks. As a result of information obtained 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 deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility Administrator Linda Gacayan and a copy of this report along with appeal rights was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20211220100932
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87564(h)(2)
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Basic Services (h) the following requirements shall apply to medications which are centrally stored. (2) centrally stored medicines shall be kept in a safe and locked place that is not accesible to persons other than employees responsible for the supervision of the cetnrally stored medications.
This requirement is not met as evidenced by:
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Facility staff will be trained on the medication regulation along with licensee. Licensee will send proof of training to LPA. Licensee will review the regulation section and provide a statement of understanding by 12/23/2021 POC date.
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Based on records reviewed, the licensee did not comply with the section cited above. VMRC staff observed licensees medications in an unlocked kitchen drawer upon the entering the facility which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/23/2021
Section Cited
CCR
87887(h)(1)
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BUILDINGS AND GROUNDS (h)Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to residents shall be stored where inaccesible to residents.
This requirement is not met as evidenced by:
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Facility staff will be trained on the regulation cited and training on storing chemicals will be conducted with facility staff. Licensee will send proof of training to LPA by 12/23/2021 POC date.
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Based on records reviewed and VMRC staff observation, the licensee did not comply with the section cited above. VMRC staff observed disinfectants unlocked and accesible to residents in the kitchen and bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
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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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20211220100932
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
HSC
1569.58
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 ... any employee, prospective employee, or person who is not a client and who has done any of the following: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan by 12/23/2021 POC date on a timeline for staff training to be conducted for Infection Control/Mitigation Plan, and the most recent PIN related to masking guidance. The training shall be completed by 01/15/2022.
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Based on LPA observation, records reviewed, and VMRC staff observation facility staff is not wearing masks inside the facility.
This violation poses an immediate health, and safety risk to residents in care.
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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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4