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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804012
Report Date: 10/07/2025
Date Signed: 10/07/2025 01:40:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250815134443
FACILITY NAME:HAVEN'S HOUSE OF ASSISTED LIVINGFACILITY NUMBER:
486804012
ADMINISTRATOR:THOMAS, APRILFACILITY TYPE:
740
ADDRESS:2769 BRADBURY WAYTELEPHONE:
(415) 374-5703
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 3DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, April ThomasTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Staff abandoned resident at hospital.
INVESTIGATION FINDINGS:
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At approximately 11:30AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Administrator, April Thomas.
During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff abandoned resident at hospital.”
The complaint alleged that Resident 1 (R1) was transported to Kaiser Emergency Room on the morning of 08/15/2025, following a fall at the facility. Reporting Party (RP) stated that approximately 15 minutes after R1 arrived at the hospital, facility staff were contacted by hospital staff to coordinate discharge, but Administrator 1 (S1) stated that R1’s room had already been filled and R1 was not welcome back to facility. RP also stated that around 12:15 p.m. the same day, the Administrator 1 (S1) returned to the hospital and dropped off R1’s belongings at the security desk without his personal medications or oxygen tank.
Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 5
Control Number 21-AS-20250815134443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025
NARRATIVE
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Continued from LIC9099...

LPA conducted interviews with S1, who confirmed that R1 had requested to go to the hospital after reporting a fall. S1 stated that they told R1 they would need to pay a transportation fee before to be taken to the hospital for his doctor appointments. R1 declined to make payment without a receipt, the administrator called 911, and R1 was transported by emergency services. S1 confirmed that later the same day, they informed the hospital that R1 would not be returning to the facility and that they dropped off his belongings at the hospital. S1 stated they did not follow up info regarding R1’s condition and could not provide any documentation to support her claim that R1 declined to return to the facility. No written statements, logs, or records were provided to indicate that R1 refused to return. Additionally, R1 had paid rent through 08/22/2025.

Based on interview conducted, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250815134443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2025
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents...
(a) In addition to the rights listed in ...: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict... This requirement was not met as evidenced by:
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Administrator agrees to read regulation 87468.2 and submit written declaration acknowledging the understanding of regulation and the facility policies and procedures. Items to be submitted by date 10/21/2025.
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Based on interviews and LPA observation of records, it was determined Facility refused to accept the resident (R1) back from the hospital. This poses an immediate health, safety or personal rights risk to persons in care.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250815134443

FACILITY NAME:HAVEN'S HOUSE OF ASSISTED LIVINGFACILITY NUMBER:
486804012
ADMINISTRATOR:THOMAS, APRILFACILITY TYPE:
740
ADDRESS:2769 BRADBURY WAYTELEPHONE:
(415) 374-5703
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:6CENSUS: 3DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, April ThomasTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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2
3
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9
Staff overcharged resident.
INVESTIGATION FINDINGS:
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At approximately 11:30AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, April Thomas.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff overcharged resident.”
The complaint alleged that the facility administrator charged Resident 1 (R1) for transportation and prescription medications that are typically delivered free of charge by the pharmacy. The Reporting Party (RP) stated that R1 normally receives medications by mail from Kaiser at no cost, but was still charged by the administrator for medication-related services and $15 for resident transportation.
LPA interviewed the administrator (S1), who stated that the facility charges a flat fee of $6 for medication delivery services and resident transportation, as outlined in the facility’s admission agreement.
Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250815134443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025
NARRATIVE
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Continued from LIC9099...

S1 denied over charging residents for the cost of medications themselves. LPA requested documentation and reviewed the admission agreement, which reflected a $6 service fee related to medication delivery. No documentation or statements were found indicating that residents were charged for medications beyond the agreed-upon delivery and transportation fee.

Based record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5