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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 02:15:30 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
05/09/2022 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:
12:37 PM
MET WITH:House Manager, Maria KnightTIME COMPLETED:
02:03 PM
ALLEGATION(S):
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Staff did not assist resident with their medication
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 complaint investigation LPA requested documentation (physicians report, MARS from January through June 2022, staff contact information, staff schedule and hospital discharge paperwork) and completed interviews with staff, house manager, RP and Licensee. Records reviewed showed that the medication was not logged as given/given (2/2022 and 3/2022). House Manager stated "new Licensee took over in February 2022. Medications could not be verified for residents in care due to poor record keeping by the previous Licensee". The allegation is SUBSTANTIATED.

Exit inteview completed. Appeal rights and a copy of the 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-20220509082643
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 A
07/15/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and DentalCare (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the followng:(4) The licensee shall assist residents with self-administered medications as needed.
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Licensee has put MARS in place, working with pharmasist and physician to work with facility. Facility is currently in the process of updating record keeping. Training will be set up with a pharmasist and a date for training to be provided to CCL by POC date. Training material and sign in sheet to be provided to CCL once completed.
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This requirement was not met as eivdence by: LPA observation of medication logs, lists and hospital discharge paperwork. Records reviewed showed that the medication were not logged as given/given (2/2022 and 3/2022). This posses an immediate health and safety risk to resident(s) 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: 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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