286803790-4-16-2021-21-AS-AELT-C25RXQ-20210416132503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 04/14/2021
Date Signed: 04/16/2021 01:25:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	ROSE HAVEN LLC		FACILITY NUMBER:	286803790
ADMINISTRATOR:	FRANCO, RHON		FACILITY TYPE:	740
ADDRESS:	520 SANITARIUM RD		TELEPHONE:	(707) 963-3748
CITY:	ST HELENA	STATE: CA	ZIP CODE:	94574
CAPACITY:	32	CENSUS: 8	DATE:	04/14/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Suresh Mahawar/ Rose Mahawar/Rhon Franco		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Regional Office Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers and Licensing Program Analyst Angela Elliott, met via tele-visit with Suresh Mahawar- Licensee, Rose Mahawar- Manager and Rhon Franco- Administrator. This office meeting is being conducted via tele-visit due to COVID -19 precautions. The purpose of today's office meeting is to discuss status of facility and Non-Compliance Conference (NCC) held on 8/4/2020. Issues discussed at today's office meeting include: Per NCC:Licensee will send in weekly staff schedule, handwritten time sheets, and electronic time sheets for the month of August and ongoing weekly. It was identified there were gaps in information submitted. It was decided that schedule information will be sent biweekly based on schedule development. Facility needs to ensure Administrator duties are being performed as well as residents needs being met per regulation. It was also discussed drafting a document outlining who is doing housekeeping tasks, who is trained to give medications, who is providing activities, who is providing caregiver services etc. would benefit the facility Per NCC: Reporting Requirements-Licensee will train all staff on reporting requirements, submit a written plan of how facility will ensure that all reports regarding death, incidents, refusal of meds/med errors, etc. are submitted to licensing within time frames per regulation. It was discussed citation was issued on 3/8/2021 for Reporting Requirements 87211(a((1)(D). POC component was Administrator /Manager agrees to train all staff on reporting requirements and submit proof of training by POC due date of 3/22/2021. Per NCC: Activities-Licensee will submit activity schedule for residents. It was identified this has not been submitted. It was established Rhon is designated as Administrator, cook, medication person, NOC shfit staff and activity coordinator on facility schedule. It was noted scheduled structured activities with a designated staff need to be occurring, in addition to on-going activities that are relevant and responsive to resident need, interest and choice.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROSE HAVEN LLC	FACILITY NUMBER: 286803790
	VISIT DATE: 04/14/2021

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Per NCC: Training-Licensee will ensure all staff will have training per Regulations on file for review, including but not limited to: Food Service, Dementia Care, Safe and Sanitary Practices, Personal Rights, Reporting Requirements, First Aid, CPR, etc. Rose confirmed staff are cross trained in all areas when Rhon is busy with other tasks.

Per NCC: Food Service-Licensee agrees to send weekly menus with food receipts. It was identified there have been a lack of menus submitted. It was decided moving forward food receipts and menu will be sent on a monthly basis..

Per NCC: Licensee has agreed to work with TSP-It was discussed lack of transparency created barriers in having a successful working relationship with TSP. Facility was encouraged to have an open dialogue with CCL and bring any issues forward to ensure facility success.

Licensee, Manager and Administrator agree to:

Submit a document outlining persons responsible for doing housekeeping tasks, persons who are trained to give medications, persons providing activities, and persons providing caregiver services to the residents to ensure Administrator responsibilities are being maintained. Document will also outline scheduled activity times and types of activities available.

Submit electronic timecards from 3/20/2021-present

Submit facility schedule for 3/6/2021-3/19/2021

Submit handwritten timecards for November.2020-present

Submit staff schedule, handwritten time sheets, and electronic time sheets bi-weekly

Submit proof of all staff being trained for reporting requirements for citation issued 3/8/2021

Submit menu with food receipts monthly

Updated facility resident roster.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC809 (FAS) - (06/04)

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