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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209199
Report Date: 04/12/2025
Date Signed: 04/17/2025 04:08:07 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
12/04/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20241204100214
FACILITY NAME:AT HAVEN HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: DATE:
04/12/2025
UNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Myra Torres, House Manager
Jasmin Burns, Administrator (via telephone)		TIME COMPLETED:
03:34 PM
ALLEGATION(S):
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Due to neglect, resident sustained a pressure injury
Staff retained resident with a prohibited health condition
INVESTIGATION FINDINGS:
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On 04/12/25, Licensing Program Analysts (LPAs) L. Salazar and M. Vega arrived to the facility unannounced to do deliver findings on the above allegations. LPAs were greeted by house manager, Myra stated the purpose of the visit and were allowed entry. Staff contacted Administrator vis telephone. LPAs met with House manager Myra Torres to discuss the findings of the complaint allegations.

During the investigation, LPA Salazar conducted interviews and records review. Records review show Resident R1 had a blister on their heel in September of 2024 and Home Health was ordered. Compassion Home Care Home Health records obtained for the period of 11/08/24 through 01/06/2025 states R1 to have an unstageable presssure injury on their heel and R1 should be transferred to Skilled Nursing for care. Interviews with Administrator and facility staff state facility was not observing or caring for the wound since they were not skilled professional.

Based on the information received, the preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. An immediate civil penalty is being assessed in the amount of $500 for observation of resident resulting in a prohibited condition. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

An exit interview was conducted with Administrator Jasmin Burns via telephone and house manager Myra Torres. A copy of this report and appeal rights were discussed and will be emailed by next business day. A plan of correction was developed by Administrator and reviewed with LPA at the time of visit.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2025
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-20241204100214
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 II
FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/14/2025
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as...a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by LPAs observation of records review of incident report dated 09/20/24 stating the heel wound was a small blister and Home Health records dated 11/07/24 stating R1's wound is an unstageable pressure ulcer. Interviews with staff state they did not observe or care for R1's heel wound because they are not nurses and home health services are being received. An immediate civil penalty in the amount of $500 is hereby assessed. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

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Administrator will review Home Health plan of care prior to resident's receiving home health services. Administator will provide a statement stating they have read and understood the regulation being cited.
Type A
04/14/2025
Section Cited
CCR
87615(a)
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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:LPAs observation of Home health records dated 11/07/24 stating the heel wound is an unstageable pressure ulcer and an exception to retain a prohibited condition was not submitted. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.

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Resident R1 was relocated to skilled nursing.
** POC Cleared**
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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: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2025
LIC9099 (FAS) - (06/04)
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