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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002304
Report Date: 12/16/2022
Date Signed: 12/16/2022 02:02:44 PM


Document Has Been Signed on 12/16/2022 02:02 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: 1DATE:
12/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Linda GacayanTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst Jason Lund arrived unannounced to conduct an proof of correction visit and met with Staff Linda Gacayan and explained the reason for the visit. Census 1

LPA Jason Lund received the required paperwork on 12/8/2022, LIC 200, LIC 500, LIC 501 and letter of appointment for designated Administrator for the facility.

No deficiencies cited during today’s visit. Exit interview held with Administrator Linda Gacayan . LPA Lund left copy of report.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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