216803931-10-20-2023-21-AS-DTOA-CWSUH3-20231020153516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803931
Report Date: 10/20/2023
Date Signed: 10/20/2023 03:35:31 PM

Document Has Been Signed on 10/20/2023 03:35 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: 6	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:06 PM
MET WITH:	Henri Van Meines, Administrator		TIME COMPLETED:	03:45 PM

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	10/20/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by House Manager, Helen Hocog. Administrator, Henri Van Meines was contacted and arrived later in the visit. The facility is licensed for six non-ambulatory residents and a hospice waiver for six. The facility currently provides care for six residents, three of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with House Manager, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia tested and found to be in working order. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/8/2022. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under the kitchen sink, laundry closet and storage in the garage. During inspection, LPA observed three storage sheds located in the side yard to be unsecured. Residents were not directly in access but LPA and Administrator discussed compliance. Technical Violation issued. Residents were observed engaging in discussion with staff, watching television shows or resting in their bedrooms. Residents appear to have a positive relationship with staff based on LPA observations. 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: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: 10/20/2023

NARRATIVE

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There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cart located in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found residents to have updated Physician's Reports, Needs & Service and Hospice Care Plans. During a review of staff files LPA found two staff requiring updated 1st Aid & CPR certification. Certification recently expired and facility has attempted to contact training services but pending scheduling. Technical Violation issued. Upon review of staff association on Caregiver Background Check roster LPA found that staff S1 is currently pending for clearance. S1 is currently associated and cleared for another residential care facility. Administrator has reached out to the Department and will be completing a Background Transfer Request and submit to the Regional Office. Technical Advisory.

Administrator, Henri Van Meines's Administrator Certificate 6053350740 is currently pending for renewal. LPA confirmed on CCLD Pending Application list that the certification application payment and training was received as of 5/16/2023.

LPA requested the following documents be sent to CCL by COB 11/20/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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