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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804225
Report Date: 07/02/2025
Date Signed: 07/02/2025 02:38:53 PM

Document Has Been Signed on 07/02/2025 02:38 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A&A HAVEN HOMEFACILITY NUMBER:
216804225
ADMINISTRATOR/
DIRECTOR:		ELLAZAR, STEPHANIEFACILITY TYPE:
740
ADDRESS:73 GOLDEN HINDE BLVD.TELEPHONE:
(707) 853-9915
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 5DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff Member, Edelyn Dacayanan, and Designated Representative, Bella NachorTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Edelyn Dacayanan. Designated Representative, Bella Nachor, arrived during visit at approximately 9:50AM. Facility has an approved fire clearance for five non-ambulatory residents and 1 bedridden resident for a total capacity of 6 residents and an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there are 5 residents in care and 3 staff members on site.

At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Staff Member and observed the following: Facility is a one story residence with 5 resident bedrooms, one staff room, three bathrooms, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 2 of 3 facility sinks were found to be within Title 22 Regulations of 105F to 120F. One facility sink located in a resident room was measured to be 125.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were inspected December 2024. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2025.

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: A&A HAVEN HOME
FACILITY NUMBER: 216804225
VISIT DATE: 07/02/2025
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Continued from LIC809

LPA observed that there is a small storage space between one resident room and the facility staff room. This space is not shown on facility's sketch. LPA was also informed that the current staff room may be converted into a private resident room. LPA requested that an updated facility sketch be submitted to Community Care Licensing (CCL) to reflect changes. A new fire clearance request will be submitted if it is determined that the staff room will be converted into a private resident room.

LPA reviewed staff and resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. Administrator Certificate for Stephanie Ellazar (6070922740) was current with an expiration date of 06/06/2026. Administrator Certificate for Bella Nachor (7008140740) was current with an expiration date of 05/27/2027.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610E)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 08/02/2025.

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, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2025 02:38 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 07/02/2025 at 02:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: A&A HAVEN HOME
FACILITY NUMBER: 216804225

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. 1 out of 3 facility sinks was measured at 125.2F. Sink was observed to be located in a resident's room. This which poses a potential health, safety or personal rights risk to residents in care.
POC Due Date: 07/14/2025
Plan of Correction
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Licensee to submit a 10 day water temperature log. Log to be started on 07/03/2025 and end on 07/13/2025. Log to include date, location of sink, water temperature, and time of temperature check and submitted to CCL by POC due date of 07/14/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
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