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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803931
Report Date: 11/16/2020
Date Signed: 11/17/2020 09:51:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:HAVEN HOUSE OF SAN RAFAELFACILITY NUMBER:
216803931
ADMINISTRATOR:MEINES, HENRI VANFACILITY TYPE:
740
ADDRESS:45 MERIAM DRTELEPHONE:
(201) 694-4144
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
11/16/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Henri Van Meines - Licensee/AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Fernandes-Goes & Sarangi conducted an unannounced virtual pre-licensing inspection. LPAs contacted licensee Henri Van Meines through a telephone call and started a tele-visit inspection due to COVID-19. This is a change of ownership (CHOW). Fire clearance has been approved for 6 non-ambulatory residents. There is no Hospice Waiver on file at this time, Dementia Program Plan has been approved by the application unit. LPA will conduct a component III orientation with Henri Van Meines – Licensee/Administrator. There is a total of 6 residents with 2 residents under Hospice Waiver. LPAs will conduct a component III orientation with Henri Van Meines - licensee/administrator.

Haven House of San Rafael is a program for senior residents. The facility has been approved by Marin Fire Department. Facility plans on having awake staff; there will be 3 shifts of staff at the facility at all times, as per Henri Van Meines – Licensee/Administrator

LPAs toured facility with Henri Van Meines – Licensee/Administrator on 11/16/2020 at 12:30 PM and observed: Facility is a one floor building. The facility was inspected and found to be cleaned and at in good repair. Exits were equipped with auditory devices and delay egress, and 2 out of 3 doors weren’t activated at the time of the visit, however; licensee/administrator turned them on during the visit and understands that auditory devices must be on at all times. Fire Extinguisher was found to be last charged on 12/2019 at the time of the visit. Smoke detectors and carbon monoxide detector were found to be working at this time. Hot water temperature checked 110.4 degrees F. The facility has a phone line designated for residents use. There was an ample supply of personal hygiene products, bedding and linens, utensils, dishes, and cookware as per facility. There were emergency supplies available at the time of the visit.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HAVEN HOUSE OF SAN RAFAEL
FACILITY NUMBER: 216803931
VISIT DATE: 11/16/2020
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Personnel records and resident’s records are stored at the facility in a locked cabinet in the kitchen area. The floor includes kitchen, living room area, family room, bedrooms including staff room, shower bathroom, dining room, and garage. Resident's bedrooms have all required lighting & appropriate furnishings as per Title 22 Regulations. Activities are available for residents as per licensee/administrator. Resident records, medication will be locked on this level in a medication cart, toxins are kept locked in a designated cabinet in the garage; facility has first aid kit. The floor will also consist of a laundry room. There is outdoor space for activities.

A virtual review of six resident & two staff records was conducted. LPAs reviewed resident’s files and learned that 6 of 6 residents have an updated physician’s assessment – LIC 602 and cleared TB test results. Medications were not reviewed at this time due to visit being conducted virtually. Licensee/administrator understands that all medications must have a doctor’s order and medication must match the order. As per licensee/administrator all medication has a doctor’s order. LPAs reviewed a sample of staff records and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions under the facility that is licensed at this time. In addition, sample review of staff file shows that Direct care staff additional training requirements are on file. LPAs were presented with proof of CPR & 1st Aid certification for sample staff files that were reviewed virtually. Disaster Drills are conducted quarterly, and last drill dated 11/2/2020.

Facility needs to have an approved Hospice Waiver to be licensed.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020
LIC809 (FAS) - (06/04)
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