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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803931
Report Date: 08/01/2025
Date Signed: 08/01/2025 02:26:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2025 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20250729125340
FACILITY NAME:HAVEN HOUSE OF SAN RAFAELFACILITY NUMBER:
216803931
ADMINISTRATOR:MEINES, HENRI VANFACILITY TYPE:
740
ADDRESS:45 MERIAM DRTELEPHONE:
(201) 694-4144
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 4DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:House Manager, Helen Hocog, and Licensee, Harry Van MeinesTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility staff are using bedrails to restrain resident
Personal Rights
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegations and met with House Manager, Helen Hocog. Licensee, Harry Van Meines, arrived during visit at approximately 12:00PM.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility staff are using bedrails to restrain resident," and "Personal Rights." Complainant alleged the following: Resident 1 (R1) doesn't want to be put in bed at 7:30PM and wants to go to bed at 10:00PM. Facility put a camera and motion sensor in R1's room to monitor them, and facility staff have added a second railing to R1's bed to prevent them from getting out of bed. Photo provided to LPA showed a resident's bed with two half rails pulled up. The half rails were shown to be affixed at the top and lower halves of the bed with a small gap in the middle. During visit on 08/01/2025, Interview conducted with House Manager and Staff Member 1 (S1) revealed that they use the
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20250729125340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAVEN HOUSE OF SAN RAFAEL
FACILITY NUMBER: 216803931
VISIT DATE: 08/01/2025
NARRATIVE
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Continued from LIC9099

second half bed rail and the gait belt as a safety precaution for R1. Per interviews, the gait belt is used as a safety precaution for R1 when staff are doing other tasks such as cooking or providing care to other residents. LPA was informed that the video camera has no audio and was placed as an additional safety precaution to notify Night Shift staff when R1 gets up at night. Interviews further revealed that R1's family was verbally notified of the camera/video monitoring. Interview conducted with R1 revealed that they preferred to go to bed at 10:00PM but usually get put into bed at 9PM. Per R1, they are unable to get out of bed on their own due to their recent injury and would require assistance to leave. LPA conducted a walkthrough of the facility and observed the following: R1's bed had two half bed rails creating a full bed rail (picture taken). LPA also observed that R1 had a white gait belt around their wheelchair.

Review of R1's file showed that they are not receiving hospice services at this time and do not have a physician's order for use of bed rails or for use of a gait belt. There is also no documentation in the file regarding camera/video monitoring for R1's room.

Based on record review, interviews conducted, and observations made, these allegations are Substantiated.
A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250729125340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAVEN HOUSE OF SAN RAFAEL
FACILITY NUMBER: 216803931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2025
Section Cited
CCR
87608(a)(5)(B)
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*Amended* 87608 Postural Supports:(a)...supports may be used...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of...hands or feet. (B) Bed rails that extend the entire length...prohibited except for residents currently receiving hospice care...This
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*Amended* Licensee removed secondary bed rail during LPA visit. LPA also observed gait belt on R1's wheelchair was removed during visit. Deficiency cleared during visit. Licensee to request from R1's physician to have a half bed rail order for mobility and submit proof of order. Licensee to submit
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requirement was not met as evidenced by: Based on records, observations, and interviews, Licensee did not comply with the section cited above. R1 had a gait belt around their wheelchair and two half bed rails as a full bed rail. This poses an immediate health and safety risk to residents in care.
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In-Service training for all staff reviewing Postual Support Regulation. Training to include Topic, Date, Trainer,Staff Job Roles,and Signatures. Proof of Physician Order and In-Service Training to be submitted to CCL for review and approval by POC due date of 08/15/2025.
Type B
08/15/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities:(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This
requirement was not met as evidenced by:
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 Licensee to immediately remove camera from R1's room and submit proof to CCL by POC due date of 08/15/2025.
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*Amended* Based on interviews conducted, Licensee did not comply with the section cited above. R1 has a camera in their room without the written approval/consent of the Department or R1's Responsible Party. This is a potential health and safety 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250729125340
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAVEN HOUSE OF SAN RAFAEL
FACILITY NUMBER: 216803931
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2025
Section Cited
CCR
87468.2(a)(6)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a)...residents...shall have all of the following personal rights:(6) To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by:
Based on interviews, Licensee did not comply
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Licensee to submit In-Service training for all staff reviewing all regulations on the Personal Rights of Residents. In-Service Training to be submitted to CCL for review and approval by POC due date of 08/15/2025.
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with the section cited above. R1 stated that they go to bed earlier than they prefer and are also unable to get out of bed on their own. This is a potential health and safety 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4