216803931-7-21-2023-21-AS-KMOA-CU6N3U-20230728100654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803931
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:23:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/08/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230508141248

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: 6	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff Member, Helen Hocog, and Administrator, Henri (Harry) Van Meines		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Illegal Eviction
Facility did not make reimbursement to resident's representative
Facility did not provide copy of admission agreement to resident's representative

INVESTIGATION FINDINGS:

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At approximately 9:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation and met with Staff Member, Helen Hocog. Administrator, Henri (Harry) Van Meines, arrived later during visit at approximately 10:35AM.

During the course of the Investigation, LPA made observations, reviewed documents, and conducted interviews.
There is an allegation of Illegal Eviction. The Report received on 05/08/2023 states that on 03/17/2023, the Facility informed Resident 1’s (R1’s) Responsible Party that they could not return to the facility due to needing a higher level of care. The Reporting Party informed Community Care Licensing (CCL) that R1 was evicted from the facility on 03/17/2023 when the Facility called 911 to take R1 to the hospital due to aggression and behaviors. Review of Documents indicated that R1’s Responsible Party decided to move R1 out of the Facility on 03/21/2023, and their belongings were removed from the facility on 03/22/2023.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230508141248

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/21/2023

NARRATIVE

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Continued from LIC9099

Review of R1’s Hospital Records indicated that R1’s belongings were removed from the facility prior to R1 being discharged from the Hospital on 03/27/2023. This allegation is Unsubstantiated.

There is an allegation that Facility did not provide a copy of the Admissions Agreement to Resident Representative. LPA received conflicting information regarding R1’s Admissions Agreement. Review of R1's Admissions Agreement showed only one page available. Interview conducted with Facility Administrator stated that R1’s Representative did not return their signed Admissions Agreement for R1’s file. Interview conducted with R1’s Representative stated that they did not have the Admissions Agreement in their possession. Review of Title 22 Regulation - 87507 Admission Agreements(c) states “Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission…” Per Title 22 Regulation - 87507 Admission Agreements(c), Facility had 7 days to have R1’s Admissions Agreement signed following their admission to the Facility. Review of Documents showed that R1 was admitted to the hospital on 03/17/2023, three days after moving in. R1 did not return to the Facility and their belongings were removed and vacated from the facility on 03/22/2023. This allegation is Unsubstantiated.

There is an allegation that Facility did not make reimbursement to Resident Representative. The Report received on 05/08/2023 states that the Facility did not reimburse R1’s Representative for the remainder of March 2023. Documents reviewed showed that the Facility owed fees for when R1 moved into the Facility on 03/14/2023 to when R1’s Responsible Party removed R1’s belongings from the Facility on 03/22/2023. Documents reviewed indicated that the refunds made to R1’s Representative were accurately calculated and were appropriate per Title 22 Regulations and the Health and Safety Code section 1569.652. This allegation is Unsubstantiated.

A finding that a 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 LIC811 (Confidential Names) and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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