216804230-6-26-2026-21-AS-VBEI-DVRUTE-20260707155150

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804230
Report Date: 06/26/2026
Date Signed: 06/26/2026 03:44:56 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
06/17/2026 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20260617104728

FACILITY NAME:	HAVEN RESIDENCE OF SAN RAFAEL		FACILITY NUMBER:	216804230
ADMINISTRATOR:	MEINES, HENRI VAN		FACILITY TYPE:	740
ADDRESS:	70 MERIAM DR		TELEPHONE:	(201) 694-4144
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	06/26/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	House Manager, Sheaena Hocog, and Licensee, Harry Van Meines		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not follow reporting requirements

INVESTIGATION FINDINGS:

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At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a complaint investigation regarding the above allegation and met with House Manager, Sheaena Hocog. Licensee, Harry Van Meines, arrived during visit at approximately 11:50AM.

During the course of the investigation, the Department made observations. There is an allegation of "Staff did not follow reporting requirements." Per report, a staff member was punched in the face by a resident approximately 2-3 weeks ago and was reported to management and the Licensee. Report stated that it was believed that the incident was not reported to Community Care Licensing.

LPA contacted the Complainant for additional information. Complainant refused to provide information such as who the resident was, when the incident occurred, and if there were any witnesses to the event.
Continued on LIC9099

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

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-20260617104728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 RESIDENCE OF SAN RAFAEL	FACILITY NUMBER: 216804230
	VISIT DATE: 06/26/2026

NARRATIVE

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Continued from LIC9099

Per Title 22 Regulations, Reporting Requirements, 87211(a)(1)(D), "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents..."

Review of Title 22 Regulations indicated that an incident should be reported to Community Care Licensing if the welfare, safety, or health of a resident is threatened by a staff member or other residents in the facility. Because the incident alleged in the complaint involved a resident hitting a staff member, this incident was not necessarily required to be reported to the Department.

Based on review and observation of Title 22 Regulations, this allegation is Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026

LIC9099 (FAS) - (06/04)

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