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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002304
Report Date: 04/28/2022
Date Signed: 04/29/2022 07:19:31 AM


Document Has Been Signed on 04/29/2022 07:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda Gacayan - LicenseeTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Required Annual Inspection Visit. LPA met with licensee and explained purpose of visit. Administrator Certificate expires 09/18/2022.
The facility is licensed for a capacity of 6 Non-ambulatory/ bedridden residents. Facility has a hospice waiver for 2 to receive hospice care services. There is 1 resident receiving hospice services at this time.

LPA and Licensee inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, laundry room, and dining room area. LPA observed sufficient seven days non-perishable and two days perishable food supplies in the main kitchen. LPA observed centrally stored medications. Hot water temperature was measured in kitchen sink and it measured at 108.4 F degrees which is in the required range of 105 to 120 degrees. LPA observed there was a Carbon Monoxide monitor in facility. LPA observed cabinet under sink in kitchen was locked and toxins stored under sink. LPA verified the last Fire Drill was conducted on 03/11/2022 . Fire Extinguishers expired 02/03/2022. Staff and visitors enter the facility through ringing the locked front door, sanitizer, thermometer, sign in sheets were observed. COVID-19 signs posted in front entry way.

LPA reviewed (2) staff files. All staff is fingerprint cleared and associated to the facility and staff currently have First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA reviewed 3 resident files which have all Community Care Licensing (CCL) documents as required.. LPA reviewed 3 of resident medication files, which were completed .

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. See LIC 809-D. Appeal Rights Given. Failure to correct the deficiency may result in civil penalties.
Exit interview held with Licensee. LPA left copies of reports and appeal rights with licensee.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2022 07:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in fire extinguishers tags were not checked by fire protection services and expired 2/3/2022 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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 Licensee agreed to purchase new fire extinguishers during annual inspection visit. LPA observed new fire extinguisher purchased on 4/28/22. An immediate civil penalty of $500.00 was assessed. No further action required.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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