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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247208959
Report Date: 08/02/2022
Date Signed: 08/02/2022 01:38:49 PM

Substantiated


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
07/26/2022 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220726110502
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: 5DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Jasmin Burns, AdministratorTIME COMPLETED:
01:37 PM
ALLEGATION(S):
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Staff will not accept resident back at facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility. LPA met with Administrator Jasmin Burns and Maria Knight, Manager . LPA went over the allegation and the finding with the Administrator. During the course of this complaint investigation LPA interviewed staff, obtained and reviewed facility records. It was determined based on the interviews and records reviewed that the above allegation is SUBSTANTIATED.

Based on LPA interviews and reviewed records, LPA found that Administrator Jasmin Burns did not issue an eviction notice and did not follow the 87224 Eviction Procedures to legally evict Resident (R1). Per interviews, it was reported facility did not accept R1 once resident was cleared and discharged from the hospital. Per Admissions Agreement signed and dated on 12/20/2021, R1 has been living at the facility since 12/20/2021.
Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.Exit interview was conducted. LPA provided the facility with a copy of this report and Appeal Rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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 2
Control Number 24-AS-20220726110502
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AT HAVEN HOME
FACILITY NUMBER: 247208959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2022
Section Cited
CCR
87224(d)
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87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.
This requirement was not met as evidenced by:
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Administrator shall review Title 22, Division 6, Chapter 8, Section 87224: Evictions Procedures. Administrator shall provide in writing that the regulation has been read and understood by 08/08/2022. Administrator stated she will serve an eviction notice by 08/03/2022 to R1's responsible party.
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Based on observation, record review and interview, the Licensee did not serve the resident with a proper 30-day eviction notice, which poses a Potential Health, Safety and Personal Rights risk to persons 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: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2