216803931-10-14-2022-21-AS-DTOA-CK7PWZ-20221014114133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803931
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:04:56 PM

Document Has Been Signed on 10/14/2022 12:04 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	HAVEN HOUSE OF SAN RAFAEL		FACILITY NUMBER:	216803931
ADMINISTRATOR:	MEINES, HENRI VAN		FACILITY TYPE:	740
ADDRESS:	45 MERIAM DR		TELEPHONE:	(201) 694-4144
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 5	DATE:	10/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:29 AM
MET WITH:	Harry Van Meines, Administrator		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/14/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by staff Edwin Lopez-Taitano. Administrator Henri Van Meines was contacted and arrived for the inspection. The facility is a 6 bed one story home that currently provides care for 5 residents, 2 of which are on hospice and some with a diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/1/2021 at the time of the visit. Smoke and carbon monoxide detectors were found throughout the facility are connected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods properly stored as required by Title 22 Regulations with balanced meals and alternative meal options for residents. LPA conducted a sample file review and found all reviewed staff to have current 1st Aid & CPR training certification on file. Medications and facility records are located in the kitchen with medications secured in designated cart. LPA observed an oxygen tank located in resident bedroom with appropriate signage posted for required safety precautions. Toxins are stored in a locked facility laundry room and maintenance closets which were found to be secured upon observation. There was a supply of hygiene products and paper products available for resident use. All resident bedrooms have lighting & appropriate furnishings. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAVEN HOUSE OF SAN RAFAEL	FACILITY NUMBER: 216803931
	VISIT DATE: 10/14/2022

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Infection Control:
Facility has submitted an Infection Control Plan to CCLD for review. All residents and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and residents ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and residents are observed for symptoms and temperature based on change of condition.

No deficiencies cited during the inspection.

LPA requested the following documents be sent to CCL by COB 10/28/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility resident’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022

LIC809 (FAS) - (06/04)

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