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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209199
Report Date: 08/01/2023
Date Signed: 08/04/2023 08:12:35 AM


Document Has Been Signed on 08/04/2023 08:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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: 12DATE:
08/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Manager Maria KnightTIME COMPLETED:
12:00 PM
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On 8/1/23 at 10:20 a.m. Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit. LPA was greeted at the facility by caregiver and allowed entry into the facility. LPA met with Manager Maria Knight who was already at the facility.

LPA was informed facility's water well has had no water as since 7/29/23. LPA spoke with Manager regarding water well being dry since 7/2923. Manager stated on 7/29/23 at 5:45 am care provider noticed no water and called Manager & Administrator. Manager and Administrator arrived at the facility shortly after. Manager stated water was off for about 2 hours and was completely restored by about 8:45 a.m. LPA asked if the resident's daily routine was interrupted and Manager stated no one's routine was interrupted.

Manager stated the facility had one pellet of water delivered which has about 1872 bottles of water and have 2 pellets of bottled water on reserve. A neighbor of the facility allowed the facility to access their water well as a temporary fix. Facility is working with Living Wells and anticipates the job to be completed in about three weeks. If the well cannot be fixed at that time the company will bring water citrons to the facility to provide water (water containers). Currently the facility is utilizing paper plates and cups in order to use less water from the well.

Facility has an Emergency Disaster Plan posted in the facility with 2 temporary locations listed. Facility also has an emergency exit map located in the facility and accessible to staff & residents.

Exit interview was conducted and a copy of this report was provided to Manager Maria Knight.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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