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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002304
Report Date: 11/28/2022
Date Signed: 11/28/2022 10:08:41 PM


Document Has Been Signed on 11/28/2022 10:08 PM - 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: 2DATE:
11/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Linda Gacayan TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst Jason Lund arrived unannounced to conduct an case management visit and met with Administrator Linda Gacayan and explained the reason for the visit. Census 2

LPA Jason Lund spoke with Administrator Linda Gacayan regarding taking residents that are not Valley Mountain Reginal Center (VMRC). As of 11/28/2022 the facility has two residents that are not (VMRC). Administrator Erlinda Gacayan sent a email to VRMC that the facility is rendering services to VMRC as of 1/1/2023.

LPA Jason Lund observed that the facility doesn’t active Administrator at this time. Administrator Linda Gacayan Administrator certificate expired on 9/18/2022.

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 Administrator Linda Gacayan . LPA Lund left copies of reports and appeal rights with Administrator Linda Gacayan.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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 11/28/2022 10:08 PM - 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: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2022
Section Cited

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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator...
This requirement was not as evidenced by
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Based on LPA Lund observation the facility doesn't have the facility doesn’t active Administrator at this time. This poses a potential health, safety and personal rights 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: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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