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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803931
Report Date: 11/19/2024
Date Signed: 11/19/2024 12:47:13 PM

Document Has Been Signed on 11/19/2024 12:47 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HAVEN HOUSE OF SAN RAFAELFACILITY NUMBER:
216803931
ADMINISTRATOR/
DIRECTOR:		MEINES, HENRI VANFACILITY TYPE:
740
ADDRESS:45 MERIAM DRTELEPHONE:
(201) 694-4144
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:House Manager, Helen Hocog, and Licensee/Administrator, Henri (Harry) Van Meines TIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with House Manager, Helen Hocog. Licensee/Administrator, Harry Van Meines, arrived during visit at approximately 10:45AM. Facility is a Residential Home for the Elderly and provides care and assistance for Older Adults. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 6 residents in care, and 3 staff members on-site.

At approximately 9:50AM, LPA reviewed the Facility's Staff Roster and all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, 1 staff room, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguisher was last inspected December 2023. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted October 2024.

At approximately 10:50AM, LPA reviewed staff files, resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure.

Administrator's Certificate for Henry (Harry) Van Meines (7020155740) was current with an expiration date of 08/18/2025.

Continued on LIC809

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 HOUSE OF SAN RAFAEL
FACILITY NUMBER: 216803931
VISIT DATE: 11/19/2024
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Continued from LIC809

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610E)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Documents to be submitted to Community Care Licensing (CCL) by due date of 12/19/2024.

Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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