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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 02:17:38 PM

Unsubstantiated


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
05/09/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220509082643
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:
02:04 PM
MET WITH:House Manager, Maria KnightTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
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9
Staff did not notify resident's responsible party of resident's incident
INVESTIGATION FINDINGS:
1
2
3
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5
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7
8
9
10
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13
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 (HM), 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 complaint investigation LPA requested documentation (physicians report, MARS from January through June 2022, staff contact information, reviewed phone records,staff schedule and hospital discharge paperwork) and completed interviews with staff, house manager, RP and Licensee. Interviews disclosed that House Manager contacted POA for resident at time of incident.

Although the allegation may or may not have occurred it does not meet the departments standards. The allegation is UNSUBSTANTIATED.

Exit interview completed. A copy of this report given.
Unsubstantiated
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)
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