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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800687
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:14:46 PM

Document Has Been Signed on 02/29/2024 12:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CELEBRITY HAVEN IIFACILITY NUMBER:
286800687
ADMINISTRATOR:FUENTES, ALMAFACILITY TYPE:
740
ADDRESS:2212 TROWER AVE.TELEPHONE:
(707) 251-5722
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 3DATE:
02/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Alma FuentesTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:00AM to conduct an Annual Required inspection and was greeted by Administrator. LPA and Administrator discussed the purpose of the visit.

LPA initiated a tour of the facility around 10:15AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 134 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Administrator immediately turned down the hot water heater. Administrator agrees to keep a hot water temperature log until water temperature gets into the required range per regulation. LPA observed the drawer containing knives did not have a lock on it. However, staff are constantly supervising residents. LPA and Administrator discussed keeping a magnetic lock on the drawer to ensure extra security.

Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the pantry as well as the shed outside and are rotated.

Fire extinguishers were last serviced October 12, 2023. Smoke detectors located throughout the facility were tested and operational during inspection. LPA and Administrator were unable to locate the carbon monoxide detector. Administrator agreed to purchase a new carbon monoxide alarm and have it installed this week. Most recent fire/disaster drill was conducted 01/04/2024.


Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CELEBRITY HAVEN II
FACILITY NUMBER: 286800687
VISIT DATE: 02/29/2024
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Continued from LIC809

Four staff files and three resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator Certificate for Administrator, Alma Fuentes (6013408740), is up to date and expires 02/11/2025. Medications and medication records were reviewed.

No deficiencies cited during inspection.

Administrator to submit updates of the following documents by 03/29/2024:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 9020 Register of Residents
Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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