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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 01/12/2022
Date Signed: 01/31/2022 01:59:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:AT HAVEN HOME IIFACILITY NUMBER:
247209199
ADMINISTRATOR:BURNS, JASMINFACILITY TYPE:
740
ADDRESS:3763 N LAKE ROADTELEPHONE:
(209) 201-9783
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:13CENSUS: 11DATE:
01/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Licensee, Jasmin BurnsTIME COMPLETED:
03:27 PM
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On 1/12/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete pre licensing visit with Licensee, Jasmin Burns. Pre-licensing visit in conjunction with the Component III. An initial application to operate a Residential Care Facility for the Elderly. A fire clearance has been granted for 13 non-ambulatory.
Change of ownership with 11 resident in care. LPA toured the facility with Jasmin Burns and "Ann" Sithrajvongsa. There are total of 9 rooms. All rooms have adequate furnishings and lighting. Hot water temperature is measured at 107 degrees F.

Cleaning supplies stored in a locked cabinet in back hallway. Resident and staff files will be kept in a locked file cabinet in an office. Medications stored in a locked cabinet cart in the office. 4 First Aid Kits contain all the required items observed. 3 fire extinguishers are present and have a service date of October 21, 2021. Smoke detectors and carbon monoxide were operating properly at time of visit. Facility has a pull station fire alarm.



LPA observed working refrigerator and freezer. Alarms were on exit doors and were operational at time of visit

Outside of the facility toured. Exits open free of obstruction. No outside hazards were observed.

Facility phone number will be (209) 384-2738.


Due to COVID precautionary measure a copy of this report will be emailed to: jasminburns17@yahoo.com. A delivered and read receipt serves as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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