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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002811
Report Date: 12/12/2025
Date Signed: 12/12/2025 02:17:20 PM

Document Has Been Signed on 12/12/2025 02:17 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAREHAVEN VALENCIAFACILITY NUMBER:
345002811
ADMINISTRATOR/
DIRECTOR:		KIM, DAVIDFACILITY TYPE:
740
ADDRESS:7545 ORANGE DRIVETELEPHONE:
(916) 928-7017
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 6CENSUS: 4DATE:
12/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Julie Smith, caregiver and Jenice Beecher, caregiverTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived at the facility unannounced to conduct a follow up case management inspection and met with Julie Smith and Jenice Beecher, caregivers, who indicated the Administrators were currently out of town. LPA stated the reason for the inspection was to follow up on several incident reports (LIC624) submitted to the Department since November 28, 2025 for resident (R1).

LPA reviewed LIC624 for November 25, 2025 (1:40 pm) when (R1) fell while walking with their walker from the patio to their room. Staff, Jenice, assisted (R1) to get up and noticed a bump on their left side of the head and provided Tylenol and an ice bag. Family was notified and stated they would check on (R1) tomorrow. The same incident report notes that (R1) felt dizzy when trying to get up, on November 26, 2025, and wanted to see their physician, so the family took them to the Emergency Room at 3:00 pm. (R1) had multiple tests taken and returned to the facility around 9:00 pm.

On November 27, 2025, staff, Julie, assisted (R1) get up from an unwitnessed fall around 3:30 pm in their room. Staff observed resident's right ankle to be swelling and provided Tylenol and ice. The administrator contacted family who stated they would visit (R1) the next day. On November 28, 2025, staff observed (R1) to have worsening pain with swelling/bruising on their right ankle, and unable to bear weight. Family was contacted and took (R1) to Urgent Care in the afternoon, where it was determined (R1) had a fractured right ankle and was sent to the Emergency Room for an Orthopedic Consult. (R1) returned at 1:00 am the following day with a splint on their right leg.

RR1) requested to be seen at the Emergency Room on December 2, 2025 due to dizziness, had multiple tests completed, and obtained an orthopedic boot the following day. Hospital discharge papers do not note any medication changes were made. All tests were negative. (R1) returned to the facility (4) hours later, with a follow up appointment with their primary care physician the next day. *cont on 809C-1. .
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAREHAVEN VALENCIA
FACILITY NUMBER: 345002811
VISIT DATE: 12/12/2025
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809C-1... The administrator stated in an email on December 4, 2025 that (R1) was fitted for an Orthopedic boot they will wear for (4-6) weeks. In addition, Physical Therapy was ordered, and (R1) will have a follow up X-ray in (4) weeks. The facility provided supporting documentation as requested to the department.

Paperwork from (R1's) Urgent Care visit on November 28, 2025 noted (R1) had a right ankle sprain/fracture from a fall the previous day and did not strike their head; however, (R1) did strike their head during a previous fall (3) days prior, but a CT scan was done and confirmed there was no injury noted.

LPA reviewed (R1's) care plan that was updated December 2, 2025, after (R1) reported dizziness and had multiple tests completed. The care plan addresses the right ankle fracture and lists (6) ways the facility will provide appropriate interventions in the areas of: Mobility, Pain Management, Safety Measures, Follow-Up care, Emotional and Social Support, and Nutrition and Hydration. The care plan also documents that all care staff will be informed of (R1's) non-weight bearing status and limitations.

The care staff today indicated that (R1) has begun receiving Physical Therapy services and will begin to be seen twice weekly, beginning next week. Staff stated (R1) is using a wheelchair and is receiving bathing once a week while the ankle heals. The care staff stated she had not fallen in a long time and suddenly fell on November 25, 2025 and stated (R1) wanted to use the bathroom independently and fell.

LPA observed (R1) to be wearing the orthopedic boot on their right foot and resting in their room watching television. LPA observed (R1) to be in a pleasant mood. LPA observed (2) other residents to be awake, watching television and (1) resident to be sleeping.

It appears the facility took appropriate measures in contacting the family and emergency medical services after (R1) fell on each occasion. There are no deficiencies issued in this report.

Exit interview with Jenice Beecher, who is authorized to sign. Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Maribeth Senty
NAME OF LICENSING PROGRAM ANALYST: Sabrina Calzada
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC809 (FAS) - (06/04)
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