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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 10/21/2020
Date Signed: 07/21/2021 02:32:21 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: 14DATE:
10/21/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rose Mahawar/Rhon FrancoTIME COMPLETED:
01:45 PM
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LPA Angela Elliott and LPM Bethany Moellers had a conference call with Rose Mahawar, Manager and Rhon Franco, Administrator. LPM and LPA were informed by Manager facility would repopulate on 10/22/2020. Manager brought up reduced staffing on NOC shift due to having 14 residents with 1 two person assist. LPA will review Non-Compliance Plan and follow-up. Incident for R1 that occurred during evacuation was also reviewed. R1 was sent out on 10/12/2020 and facility informed of right hip fracture. R1 had surgery and passed away on 10/15/2020. LPA requested additional documentation for R1 for further investigation.

LPM discussed facility is on a Non-Compliance Plan and emphasized the importance of submitting requested documentation.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
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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