247209199-4-26-2022-24-AS-SMOA-CG8JT5-20220711071921

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 247209199
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:25:11 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
04/25/2022 and conducted by Evaluator Mary Garza

COMPLAINT CONTROL NUMBER: 24-AS-20220425100214

FACILITY NAME:	AT HAVEN HOME II		FACILITY NUMBER:	247209199
ADMINISTRATOR:	BURNS, JASMIN		FACILITY TYPE:	740
ADDRESS:	3763 N LAKE ROAD		TELEPHONE:	(209) 201-9783
CITY:	MERCED	STATE: CA	ZIP CODE:	95340
CAPACITY:	13	CENSUS: 13	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	02:16 PM
MET WITH:	Licensee, Jasmin Burns and Manager Maria Knight		TIME COMPLETED:	05:32 PM

ALLEGATION(S):

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Facility retains a resident who needs a higher level of care
Facility did not arrange a meeting with responsible party prior to resident's admission

INVESTIGATION FINDINGS:

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On 4/26/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an initial 10-day complaint visit. LPA was met by Licensee, Jasmin Burns and Facility Manager, Maria Knight. LPA toured facility and completed a Health and Safety check on residents in care. Residents observed in common areas and in rooms.

LPA completed interviews with RP, Licensee and Manager. During investigation it was found that R1 was placed at facility when needing a higher level of care. LPA reviewed R1's file and did not observe a copy of a pre-appraisal assessment or physicians report. Interviews conducted showed a proper assessment was not completed prior to resident being placed at the facility. Interviews showed that R1 has a Power of Attorney (POA) for medical and monetary assistance. RP disclosed that POA was not contacted prior to R1 moving to facility. POA stated they informed facility prior to R1's move, R1 required a high level of care then available at faciilty. Manager stated that R1 signed to come to the facility.

The allegations listed above are SUBSTANTIATED. Per CA Title 22, deficiencies cited in the attached 809D. Appeal Rights given. Exit interview compelted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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 24-AS-20220425100214

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: 04/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/06/2022 Section Cited CCR 87458(b)(4)	1 2 3 4 5 6 7	87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.	1 2 3 4 5 6 7	602 completed and in R1's file. Licensee to generate files immediately upon accepting residents and complete through assessements. Training to be compelted on regulation with Administration staff. Training material and sign in sheet to be provided to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: interviews and observation. LPA conducted interviews that disclosed R1 needs a higher level of care. Records review were observed without a pre-assessment appraisal completed by facility prior to R1's move in. This posess a potential Health and Safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/06/2022 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.	1 2 3 4 5 6 7	Licensee to contact POA/RP prior to admission and making final decision to accept residents. Training to be completed with Administration staff. Training material and sign in sheet to be provided to CCL by POC date.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: interviews and observation. Interview conducted showed R1 has a POA that was not notified of R1's move. Records observed showed R1's file did not have an Admission Agreement signed by POA. This posess a potential Health and Safety risk to residents in care.	8 9 10 11 12 13 14

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 Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary Garza	TELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC9099 (FAS) - (06/04)

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