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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209199
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:17:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/18/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220418112110
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: 13DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Manager, Maria KnightTIME COMPLETED:
04:41 PM
ALLEGATION(S):
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Facility does not have sufficient food to feed the residents in care.
Facility is not providing resident safe sleeping arrangements.
INVESTIGATION FINDINGS:
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On 4/21/2022 Licensing Program Analsyt (LPA) M. Garza arrived at facility to conduct an initial 10-day complaint visit. LPA was met by DIrect Care Staff, Teny Daraphet. Facility Manager, Maria Knight was contacted and arrived some time later. LPA explained reason for visit. Facility toured and a Health and Safety check was completed on residents in care. Residents observed in rooms and in common areas. Interviews conducted with staff and residents.

Allegation: Facility is not providing resident safe sleeping arrangements.
R1 file reivewed. R1's file is incomplete and did not have a prescription indicating R1 is able to sleep on foam mattress on the floor. Interviews conducted with S1 and RP indicated R1 was sleeping on foam mattress.

Allegation: Facility does not have sufficient food to feed the residents in care.
LPA reviewed menus, food source and conducted interviews with RP, Administrator, S1 and S2. CONT...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20220418112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: AT HAVEN HOME II
FACILITY NUMBER: 247209199
VISIT DATE: 04/21/2022
NARRATIVE
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CONT...

S2 stated there is "not enough groceries to follow the menus" and R2 stated they were "still hungry" after having lunch. Food source observed. However, Facility does not have a 7 day supply of non-perishable and 2-day perishable supply of food to follow menu in place for residents.

Based on the observations, interviews and documentation reviewed, the above allegations are SUBSTANTIATED. Deficiencies cited per CA Code of Regulations Title 22 – refer to the 9099D.

Exit interview completed. Appeal rights given.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20220418112110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: AT HAVEN HOME II
FACILITY NUMBER: 247209199
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
87303(3)(A)
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87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...(A) A bed for each resident... bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding...
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Admin to complete better pre-appraisals, go more than once to assess. Obtain prescriptions from physicians for modifications in any manner. Training to be completed with all staff. Admin to submit training material and sign in sheet to CCL by POC date.
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This requirement was not met as evidence by: LPA observation and interviews conducted. Staff/RP indicated R1 was using a foam mattress on the floor to sleep. LPA observed foam mattress. This poses a potential health and safety risk to residents in care.
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Type B
04/29/2022
Section Cited
CCR
87555(26)
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87555 General Food Service Requirements(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by LPA observation and interviews conducted.
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Per Admin grocery shopping to be completed by end of day 4/21/22. Copy of reciept to LPA by 4/22/22. Facility to begin reoccurring auto ordering completed online from stores. Facility to provide all reciepts for month of May 2022 to CCL. Facility to provide plan in writting by POC date.
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LPA observed food source and interviews disclosed that the menu is unable to be followed due to insufficient food source. Facility does not have a 7 day supply of non-perishable and 2-day perishable supply of food to follow menu in place for residents. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3