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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 12/05/2024
Date Signed: 12/06/2024 07:40:47 AM

Document Has Been Signed on 12/06/2024 07:40 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 HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR/
DIRECTOR:		BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY: 13CENSUS: 12DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Jasmin Burns, Licensee/Administrator
Myra Torres, House Manager 		TIME VISIT/
INSPECTION COMPLETED:
05:21 PM
NARRATIVE
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On 12/05/24, Licensing Program Analysts (LPAs) L. Salazar and M. Garza arrived to the facility unannounced to conduct the required Health & Safety inspection. LPAs were greeted by caregiver Kenny, stated the purpose of the visit, and were allowed entry into the facility. Licensee/Administrator was called and arrived to the facility shortly after LPAs arrival. LPA Salazar discussed the details of the visit with House Manager (HM).

LPA requested additional information regarding 2 incident reports that were submitted for Resident R1.

LPA reviewed R1's file and obtained LIC602A and hospital discharge summary. X-ray report dated 09/27/24 stated R1 had a right hip fracture, not a femur fracture, as stated in the incident report. LPA did not observe a Pre-Admission Appraisal (LIC603A) or Needs and Service appraisal in R1's file. R1's admission was 09/17/24. LPA will conduct interviews and return at a later date if additional information is provided.

Based on LPA’s records review and interviews and in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D. If not corrected this poses an immediate risk to residents in care.

An exit interview was conducted with Licensee/Administrator. A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed by Licensee/Administrator and reviewed with LPA with a POC date of 12/06/24.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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 12/06/2024 07:40 AM - It Cannot Be Edited


Created By: Lisa Salazar On 12/05/2024 at 04:17 PM
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 II
FACILITY NUMBER: 247209199

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2024
Section Cited
CCR
87457(c)(1)

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87457 Pre-Admission Appraisal - General
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.
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Administrator will provide documentation verify they have read & understand the regulation requirements for admissions by POC date.
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This requirement was not met as evidenced by LPAs observation of resident's file. No pre appraisal or needs and service plan was obtained at the time of admission and not observed in file.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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