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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 10/27/2020
Date Signed: 07/21/2021 02:32:37 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: 14DATE:
10/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rhon FrancoTIME COMPLETED:
01:30 PM
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LPA Angela Elliott conducted a tele-visit with Rhon Franco, Administrator to discuss re-population of the Rose Haven Facility on 10/28/2020. LPA and Administrator reviewed the status of the facility. Administrator confirmed facility was cleaned by staff 10/22/2020 and 10/23/2020. PG & E also turned on the gas to the facility on 10/23/2020. Administrator indicated the power will be back on at the facility tonight at 11:00 PM. According to the Administrator, two Rose Haven staff will be at the facility tomorrow morning. The residents and staff will re-populate after having lunch at their current location. Per Administrator, Rose Haven staff will go grocery shopping tomorrow. LPA discussed with Administrator, due to concerns about the care and needs of the residents based on recent incidents, full body assessments will need to be completed for each Rose Haven resident when they return to the facility. Written certification that the assessments have been completed and there are no issues with the residents is required to be sent to LPA Elliott by 8:00 AM on 10/30/2020.

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

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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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