Community Care Licensing

Document Has Been Signed on 01/29/2025 08:02 PM - It Cannot Be Edited

FACILITY NAME:	AT HAVEN HOME II		FACILITY NUMBER:	247209199
ADMINISTRATOR/ DIRECTOR:	BURNS, JASMIN		FACILITY TYPE:	740
ADDRESS:	3763 N LAKE ROAD		TELEPHONE:	(209) 201-9783
CITY:	MERCED	STATE: CA	ZIP CODE:	95340
CAPACITY: 13		CENSUS: 11	DATE:	01/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	House Manager - Myra Torres		TIME VISIT/ INSPECTION COMPLETED:	08:30 PM

SUPERVISORS NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
	VISIT DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

CCR

87303(e)(1)(B)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (1) All residential care facilities for the elderly where water for human consumption is from a private source shall: (B) Following licensure, provide a bacteriological analysis of the private water supply as frequently as is necessary to assure the safety of the residents, but no less frequently than the time intervals shown in the table below. However, facilities licensed for six or fewer residents shall be required to have a bacteriological analysis subsequent to initial licensure only if evidence supports the need for such an analysis to protect residents. Licensed Capacity Analysis Required Under 6 Initial Licensing 7 through 15 Initial Licensing 16 through 24 Initial Licensing 25 or more Refer to the County Health Department for compliance with the California Safe Drinking Water Act, Health and Safety Code, Division 5, Part 1, Chapter 7, Water and Water Systems. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Testing will be on 2/4/2025, extention granted.

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in 3 out of approx 13 water access points which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	administrator will adjust water heater, and submit water temperature log for correction. Will allow additional time for proper update.

Type A

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 staff records, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Spoke to staff and will have all staff complete first aid by 2/04/2024

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review)], the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Will obtian additional training for staff, home maanager will send LPA copies once complete.

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 11 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Will obtain documentation of training from home health, and a written care plan from home health.

Type A

Section Cited

CCR

87606(b)

(b) A licensee shall notify the fire authority having jurisdiction within 48 hours of accepting or retaining any person who is bedridden, as specified in Health and Safety Code section 1569.72. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 11 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	extendtion due to talk with fire department.

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type A

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 11 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Will obtain in writing from doctor, approval for full bed rails.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type B

Section Cited

CCR

87208(c)

(c) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606, Care of Bedridden Residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Will submit plan of opperation with care of bedridden Residents.

Type B

Section Cited

HSC

1569.317

Every residential care facility for the elderly, as defined in Section 1569.2, shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility, as described in Section 1569.80. The plan shall include and be limited to the following: a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility and the circumstances in which an administrator of the facility, or his or her designee, shall notify local law enforcement when a resident is missing from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Will implement plan for elopement procedure so that all staff know appropriate actions.

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025

Link to Parent Document Below:

FACILITY NAME: AT HAVEN HOME II	FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2025

Type B

Section Cited

CCR

87613(a)(2)(B)

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Will recive home health triaining in writing and signed by home health.

Type B

Section Cited

HSC

1569.313

Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient’s rights form, the facility’s policy concerning family visits and other communication with resident clients and shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 11 resident records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	WIll provide admission aggrements for all residents.

SUPERVISOR'S NAME: Brenda Chan LICENSING EVALUATOR NAME: Martin Vega LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025