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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803931
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:11:10 PM


Document Has Been Signed on 09/24/2024 03:11 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:MEINES, HENRI VANFACILITY TYPE:
740
ADDRESS:45 MERIAM DRTELEPHONE:
(201) 694-4144
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:House Manager, Helen HocogTIME COMPLETED:
03:20 PM
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At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit, and met with House Manager, Helen Hocog. Licensee/Administrator, Henri (Harry) Van Meines, was available by telephone. The purpose of the visit was to obtain documents related to an incident report that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 09/24/2024. Report states that on 09/24/2024, Staff Member 1 (S1) informed Licensee/Administrator that Staff Member 2 (S2) was abusive to Residents 1 and 2 (R1 and R2) in 2023. Report continues to state that S2 was terminated in April 2023 and is no longer an employee of the facility.

Per discussion with Licensee/Administrator, they will be submitting an SOC-341 report to the Local Ombudsman and to the San Rafael Police Department. LPA requested that a copy be submitted to CCL.

LPA requested and reviewed documents.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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