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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 507002304
Report Date: 05/17/2023
Date Signed: 05/17/2023 12:38:45 PM


Document Has Been Signed on 05/17/2023 12:38 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:
05/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Genoveva Recto - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with licensee and explained purpose of visit. Administrator Certificate expires .
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 112.6 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 4/15/2023. Fire Extinguishers expire 3/21/2023.

LPA reviewed two (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 two (2) resident files which have all Community Care Licensing (CCL) documents as required.. LPA reviewed one (1) of resident medication files, which were complete .

No deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation.
Exit interview held with Licensee. LPA left copy of report with licensee.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023
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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