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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247209199
Report Date: 07/14/2022
Date Signed: 07/14/2022 12:38:25 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
05/02/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220502144210
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:
07/14/2022
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:House Manager, Maria KnightTIME COMPLETED:
11:39 AM
ALLEGATION(S):
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Facility in disrepair.
INVESTIGATION FINDINGS:
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On 7/14/2022 Licensing Program Analyst M. Garza arrived at facility to deliver complaint findings. LPA was temperature screened and allowed entry into the facility by Direct Care Staff. House Manager, Maria Knight was contacted and arrived some time later. LPA explained reason for visit and completed a Health and Safety check on residents in care. Residents observed in common areas and in rooms.

During the investigation RP reported that the telephone service and doorbell at the facility was not working. During visits made by the LPA is was reported by staff, Licensee and House Manager that the house phone has poor reception and does not always work properly. Licensee stated they have contacted the phone company for repair service. LPA observed the ring doorbell to funtion on the outside but the chime was not heard inside the faciilty. LPA was informed by Licensee that they did not have access to the ring doorbell service on their phone and was not given this by the previous Licensee. LPA also heard the faciilty fire alarm box to be making an alarm noise. LPA witnessed staff come over to the box and put in a code to bypass the alarm that was going off. The above allegation is SUBSTANTIATED.

Exit interview completed. A copy of appeal rights and report given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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 2
Control Number 24-AS-20220502144210
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: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee has since taken care of these issues. Staff to complete training on maintanence and operation. HM to provide a copy of training material and sign in sheet by POC date.
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This requirement was not met as evidence by: LPA interviews and observation of the phone service not working properly, fire box alarm bieng overridden and doorbell not funtioning properly.
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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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
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