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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247208959
Report Date: 09/25/2024
Date Signed: 10/04/2024 11:48:09 AM

Document Has Been Signed on 10/04/2024 11:48 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AT HAVEN HOMEFACILITY NUMBER:
247208959
ADMINISTRATOR/
DIRECTOR:		BURNS, JASMINFACILITY TYPE:
740
ADDRESS:644 DARTMOUTH COURTTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 6CENSUS: DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:19 AM
MET WITH:Administrator Jasmin BurnsTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 09/25/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a case management inspection. LPA met with Administrator and announced the purpose of the inspection.

During this visit LPA toured the facility inside and out to conduct residents safety check. The purpose of the visit was to follow-up on an incident which occurred on 9/18/2024. On 9/18/2024, Resident (R1) is a dementia resident, was found on the floor in her room. This incident was documented and reported to Regional Office, responsible party for R1 was notified.

Due to violation of Title 22 regulation deficiency is cited on attached LIC809- D

During this visit LPA requested facility files for review.

Exit interview conducted, report signed and copy of this report with appeal rights provided to administrator for facility records. fa
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 10/04/2024 11:48 AM - It Cannot Be Edited


Created By: Vadim Gorban On 09/25/2024 at 11:02 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2024
Section Cited
CCR
87705(b)

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87705 Care of Persons with Dementia. (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia.
This requirement was not observed as evidensed by:
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The administrator will provide staff apropriate dementia training, completed physician report and a complete a preventative measure for resident safety and supervision for dementia residents to LPA by POC due date
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Based on interrviewes and record reviews facility staff failed to follow title 22 regulation resulted in dementia resident unassisted falling ans breaking her pelvis.
Resident was taking the following day to the hospital were was diagnosed with broken pelvis, which poses health and safety risc 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.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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