<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208959
Report Date: 10/19/2021
Date Signed: 10/19/2021 04:15:37 PM

Document Has Been Signed on 10/19/2021 04:15 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, 1314 E SHAW AVE
FRESNO, CA 93710
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Jasmin Burns, Administrator via telephone and Maria Knight, ManagerTIME COMPLETED:
04:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility to obtain more information. Administrator Jasmin Burns was unavailable in person and designated Maria Knight to sign the report.

The visit is to respond an incident report that was submitted to CCL Office 09/07/2021 and the incident occurred on 09/06/2021 regarding Resident (R1) pinching R2. Facility staff responded immediately and redirected the residents. Administrator reported R2 had a small red mark on her right arm and skin was intact. Facility will continue to monitor residents and provide redirection when needed.

No follow-up required.

Exit interview was conducted. Administrator was provided with a copy of this report.

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.

LIC809 (FAS) - (06/04)
Page: 1 of 1