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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208959
Report Date: 11/07/2022
Date Signed: 11/07/2022 11:47:50 AM

Document Has Been Signed on 11/07/2022 11:47 AM - 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: 5DATE:
11/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Jasmin Burns, AdministratorTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) L. Cabrera conducted a subsequent Case Management visit regarding complaint # 24-AS-20220726110502, previously closed by LPA with a finding of Substantiated. Admission Agreement was not signed by the licensee or the licensee’s designated representative and does not indicate rate for basic services. Facility had improper Agreement.

LPA met with Administrator Jasmin Burns and Manager Maria Knight.

LPA provided a copy of this report to the Administrator and the Appeal Rights.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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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Document Has Been Signed on 11/07/2022 11:47 AM - It Cannot Be Edited


Created By: Lady Cabrera On 11/07/2022 at 10:57 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AT HAVEN HOME
FACILITY NUMBER: 247208959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited
CCR
87507(c)

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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document... if any, and the licensee or the licensee’s designated representative no later than seven days following admission...
This requirement is not met as evidenced by:
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Licensee will submit written statement of plan of how a copy of the admission agreement will be provided immediately to residents and resident's responsible party upon signing and Administrator will make sure admission agreement is filled out completely, to CCL by POC due 11/11/2022.
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During the complaint investigation complaint, it was reported Licensee/Administrator did not provide Admission Agreement to Resident’s (R1) Responsible Party upon signing the admission agreement and Admission agreement was not signed by the licensee, which poses a potential personal rights 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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022


LIC809 (FAS) - (06/04)
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