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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 04/12/2025
Date Signed: 04/12/2025 03:52:06 PM

Document Has Been Signed on 04/12/2025 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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: 11DATE:
04/12/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:House Manager - Myra TorresTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) M Vega and L Salazar conducted an unannounced Case Management Annual Continuation visit at approximately 10 am and was greeted by Staff, House Manager - Myra Torres. Upon arrival, LPAs observed some residents in the common area watching television. All staff at facility today were found fingerprint cleared and associated to the facility.

On today's unannounced inspection, LPA M Vega observed the common rooms to be free from obstruction and clear well-lit pathways. Kitchen clean free of unsecured medications, sharps and cleaning toxins. The kitchen has been updated since the last visit, cabinets have been painted.

Retested Water temperature at 3 points in the facility. Room 3 tested 105.6 Degrees F, Room 5 tested at 117.1 degrees F, Room 9 tested at 120.9 Degrees F.

Cabinets and areas of concern addressed in original report were cleaned and clear of dust and exterior did not have any obstructions. Uneven pavement has been fixed.

Two (2) resident files were reviewed and observed complete with Admission Agreements, Physician Reports, Needs and Services Plans/IPP current.

Two (2) Staff 1 (S1) and Staff 2 (S2) files were reviewed. Staff 1 found complete with employment applications, fingerprint clearances, Health checks and CRP/First Aid certifications current to January 19, 202, training missing for S2.

Exit interview was conducted and a copy of this report LIC809, Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of the residents in care.

Continuation on LIC 809 C

NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Martin Vega
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 22 of 26
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: AT HAVEN HOME II
FACILITY NUMBER: 247209199
VISIT DATE: 04/12/2025
NARRATIVE
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An exit interview was conducted with House Manager. A copy of this report and appeal rights were discussed and provided at the time of visit. Obtained permission from administrator for House manager Myra to sign forms.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Martin Vega
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
Page: 24 of 26
Document Has Been Signed on 04/12/2025 03:52 PM - It Cannot Be Edited


Created By: Martin Vega On 04/12/2025 at 03:16 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: 04/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation of staff records , the licensee did not comply with the section cited above in 1 out of 2, Staff 2 records did not have mentioned trainings, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator will ensure that all staff has uptodate and completed training by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Martin Vega
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 25 of 26
Document Has Been Signed on 04/12/2025 03:52 PM - It Cannot Be Edited


Created By: Martin Vega On 04/12/2025 at 03:23 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: 04/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 staff files did not have up to date fFirst Aid/CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administrator will ensure that all staff has certification by established POC.
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
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Based on observation and record review, the licensee did not comply with the section cited above did not have absentee notification plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Will provide an absentee notification plan as part of the written record of the care the resident will receive in the facility by POC.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Martin Vega
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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