<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 07/07/2021
Date Signed: 07/07/2021 01:44:05 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: 8DATE:
07/07/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rhon FrancoTIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Angela Elliott and LPA Cuadra conducted a case management- Legal/Non-compliance inspection, on 7/7/2021, at approximately 9:00 AM. LPA met with Administrator Rhon Franco. This inspection is a continuation of a previous case management conducted on 5/13/2021 to ensure compliance with Non-Compliance Conference dated 8/4/2020.

Upon arrival to facility LPAs observed S1 without a mask. LPA and Administrator had a discussion about the importance of wearing a mask on 10/30/2020. LPAs were screened upon entry but visitor log did not have temperatures documented. LPA observed documented visitor temperatures had stopped in September 2020. LPAs discussed adding documentation of temperature to screening process and the importance of staff wearing a mask. LPA's toured resident bedrooms and facility food supply. LPAs observed written activity schedule on a white board in the living room dated September 2020 and a printed activity schedule posted on the kitchen wall dated December 2019. LPAs did not observe activities being offered during the time at facility. LPA had a discussion regarding the requirement of activities at the facility based on capacity. LPAs requested to review current documentation training for staff. Administrator indicated they did not have complete records as some were electronic and they did not have access to individual training records. Administrator confirmed staff do not have annual required training. LPAs discussed the importance of having complete training records for staff available for review. LPA observed S1 giving medication to R1 in ice cream. LPAs discussed the importance of not hiding medications from residents. LPA observed R2 on the bottom floor and expressed concern to Administrator based on observation and record review about R2's needs being met. Administrator agrees to submit a plan regarding meeting the needs of R2 to Community Care Licensing by 7/12/2021. LPA's reviewed resident records while at facility.

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: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 3
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: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2021
Section Cited

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation, interview and record review Administrator/Licensee did not ensure S1 was wearing a mask and visitor temperatures documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
8
9
10
11
12
13
14
Type B
07/21/2021
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care. (5) The licensee shall assist residents with self-administered medications as needed.
(D) Assistance with self-administration does not include...hiding or camouflaging medications in other substances...This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation and interview Administrator/Licensee did not ensure staff assisted R1 with medications due to hiding medication in ice cream. This poses a potential risk to the health safety and personal rights to residents in care.
8
9
10
11
12
13
14
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: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited

1
2
3
4
5
6
7
87219 Planned Activities (e) In facilities licensed for sixteen (16) to forty-nine (49) persons, one staff member, designated by the administrator, shall have primary responsibility for the organization, conduct and evaluation of planned activities. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation , interview and record review Licensee/Administrator did not ensure staff member provided activities. This poses a potnetial risk to the health, safety and personal rights to residents in care.
8
9
10
11
12
13
14
Type B
07/21/2021
Section Cited

1
2
3
4
5
6
7
87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation, interview and record review, Administrator/Licensee did not ensure training records were maintained posing a potential risk to the health, safety and personal rights to residents in care.
8
9
10
11
12
13
14
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: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3