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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247208959
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:56:54 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2021 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20211014120039
FACILITY NAME:AT HAVEN HOMEFACILITY NUMBER:
247208959
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:644 DARTMOUTH COURTTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY:6CENSUS: 6DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Jasmin Burns, Administrator via telephone and Maria Knight, ManagerTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's dental wear is missing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility. Administrator Jasmin Burns was unavailable in person and designated Maria Knight to sign the report.

Based on interviews and records, it was determined that the above allegation Resident's dental wear is missing is UNFOUNDED. Per records review, Resident (R1) needs assistance with personal care and has been diagnosis with dementia. Staff (S1) was assisting R1 with brushing her teeth. S1 observed R1's partial dentures were missing. R1 was unable to remember how it happened. S1 did not observe any type of injuries on R1. Facility staff found R1’s partial dentures and placed them in a safe location. Facility notified R1’s Power of Attorney.

This agency has investigated the complaint alleging (Resident's dental wear is missing). We have found that the complaint was unfounded, therefore we have dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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