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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 05/13/2021
Date Signed: 05/13/2021 04:19:37 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 LLCFACILITY NUMBER:
286803790
ADMINISTRATOR:FRANCO, RHONFACILITY TYPE:
740
ADDRESS:520 SANITARIUM RDTELEPHONE:
(707) 963-3748
CITY:ST HELENASTATE: CAZIP CODE:
94574
CAPACITY:32CENSUS: 7DATE:
05/13/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rhon FrancoTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Elliott and LPA A. Canela conducted a case management- Legal/Non-compliance inspection, on 5/13/2021, at approximately 9:30 AM. LPA met with Administrator Rhon Franco. This inspection is being completed to ensure compliance with Non-Compliance Conference dated 8/4/2020.

LPA's toured the facility with the facility Administrator. LPA observed all exits to be unobstructed. Administrator informed LPA's elevator is not working. CCL was not notified. Non-Perishable food supply was found to be adequate. Bins of dry goods stored off the laundry area were observed to have vermin droppings on top of canisters and in plastic food storage bins. LPA's discussed with Administrator that bins with dropping present needed to be discarded. Administrator removed bins containing droppings. Shelves for storage in the area for dry goods also contained vermin droppings. LPA's discussed entire storage area needs to be cleaned. Perishable food was sufficient, vegetable items were observed to be wilted with brown spots of spoilage and gooey appearance and frozen foods were not stored properly with observable signs of frostbite, with open bags that were unlabeled and tears in the plastic. S1 discarded these items. LPA's inspected resident bedrooms. LPA's observed five bathrooms that were not clean of which according to Administrator three toilets were not in operating condition. R1's room had a bottle of hydrogen peroxide, nail clippers and pain relief ointments. Administrator confirmed R1 has dementia and removed items. R2's bedroom contained a pill on the night stand next to an empty cup. Administrator confirmed R2 has dementia and indicated medication was melatonin and removed pill. Night stand had a thick layer of dust over objects, carpet had white specks of debris on the surface. Sheets also had layer of white specks of debris. R2's bathroom (one of the five previously mentioned) had hair stuck to the toilet bowel and inner toilet bowel had several brown streaks. Toilet appeared to be severely stained. R3's room had urine stains on the walls. Administrator indicated that R3 does not know how to use call system button in their bedroom room and staff check on R3 every two hours. R3 lives on the bottom level of facility. Administrator also indicated all of R3's meals are served in their room. LPA's discussed facility needs to have a plan to address R3's needs as R3 is the only resident on bottom level of facility and staff and other residents are on other levels of the facility. Per Administrator R3 does not know how to utilize their signal system device
(See 809-C)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2021
Section Cited

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87555 General Food Service Requirements (b)The following food service requirements shall apply:(8) All food shall be of good quality. This requirement was not met as evidenced by:
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Based on LPA's observation and interview with Administrator, facility did not ensure quality of food was maintained. Bags of celery appeared to be spoiled. This is an immediate risk to the health, safety, and personal rights of the residents in care.
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Administrator also agrees to train staff on General Food Requirements 87555 and submit proof of training to LPA by COB 5/17/2021.
Type A
05/27/2021
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication.....and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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Based on LPA observation and interview with Administrator, facility did not ensure harmful items were secured; in R1's amd R2's bedrooms. Staff rooms were unlocked/accessible to residents and contained open Tylenol packet and medication container. This poses an immediate risk to the health safety, and personal rights of residents in care.
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Manager/Administrator also agrees to submit plan to ensure staff medications are securev to LPA by COB 5/17/2021.
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 05/13/2021
NARRATIVE
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 Facility rooms that are utilized by staff were unlocked and contained medications, hand held razors and nail clippers. Administrator locked staff rooms so they were not accessible to residents. Cleaning supplies were locked up and inaccessible to residents in care. Upon leaving facility LPA's opened front door and auditory alarm was not turned on. Administrator demonstrated that alarm was functioning but not turned on. LPA's requested Administrator to turn on alarm. This case management-legal/non-compliance inspection will need to be continued by the LPA at a later date.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.

Signature on File. (See 9099-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2021
Section Cited

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87555 General Food Service Requirement (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
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Based On LPA observation and interview with facility did not ensure food storage requirements were met as vermin droppings were present in food storage area. This poses an immediate risk to the health,
safety, and personal rights of the residents 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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4