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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 03/10/2025
Date Signed: 03/12/2025 08:18:36 AM

Document Has Been Signed on 03/12/2025 08:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HAVEN'S HOUSE OF ASSISTED LIVINGFACILITY NUMBER:
486804012
ADMINISTRATOR/
DIRECTOR:		THOMAS, APRILFACILITY TYPE:
740
ADDRESS:2769 BRADBURY WAYTELEPHONE:
(415) 374-5703
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 6CENSUS: 5DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:April Thomas - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 9:40 AM, Licensing Program Analyst (LPA) Star Stevenson made an unannounced annual required inspection of this licensed senior care facility. LPA met with April Thomas - Administrator. Four (4) staff members were present and four (5) clients in care. Staff member S1 was not associated and cleared to work at the facility (type A deficiency issued)

At approximately 10:10 AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Facility observed to have a large open and shaded outside area, All notices that are required to be posted including personal rights and "see something, say something" and ombudsman have been posted and are in a highly visible area. LPA observed activity supplies for resident use. Facility kitchen, refrigerators and freezers were clean, and a variety of healthy food was stored properly. Toxins and centrally stored meds were observed to be locked in a storage closet. Sharps and knives were locked as required. Water temperature measured within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways.

At approximately 11:15 AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents did not have current signed personal rights or consent for medical treatment (technical violations issued) None of the clients in care were indicated as bedridden on the MD LIC602 forms.

At approximately 1:30PM, LPA reviewed 4 staff records. 3 of 4 records did not contain health screening as required (technical violation issued). Evidence of current first aid and CPR training were current.

Continued on LIC809C






SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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: HAVEN'S HOUSE OF ASSISTED LIVING
FACILITY NUMBER: 486804012
VISIT DATE: 03/10/2025
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Continued for LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:



Proof of control of property (Deed or tax documents showing ownership)
LIC500- Personnel Report
LIC610E- Disaster Plan (update if need and sign)
LIC308 Current designation of facility responsibility)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator April Thomas, whose signature indicates receipt..
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 08:18 AM - It Cannot Be Edited


Created By: Star Stevenson On 03/10/2025 at 02:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAVEN'S HOUSE OF ASSISTED LIVING
FACILITY NUMBER: 486804012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview and observation the licensee did not comply with the section cited above in [1} out of [4} staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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1)Licensee to submit in writting to CCL that employee S1 will not work by 03/11/2025
2)Licensee to submit proof of S1 being associated to the facility on the Guardian website by 03/14/2025
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Star Stevenson
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


LIC809 (FAS) - (06/04)
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