286803790-8-11-2021-21-AS-AELT-C5T2AA-20210811171313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 08/11/2021
Date Signed: 08/11/2021 05:14:19 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: 9	DATE:	08/11/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Suresh Mahawar/Rose Mahawar/Rhon Franco		TIME COMPLETED:	04:20 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. Office meeting was held to review concerns on 4/14/2021. Issues discussed at today's office meeting include but are not limited to: Maintenance and Operation issues Managed Incontinence issues for residents Retaining residents with Prohibited Health Conditions No meeting Reporting Requirements Enumerated rights; ensuring residents rights are not violated General Food Service Requirements Personnel Requirements Planned Activities Care of Persons with Dementia Personnel Records Personal Rights of Residents Incidental Medical and Dental Care See LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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: 08/11/2021

NARRATIVE

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It was also discussed staff at Manager's other facility were not transparent in sharing information regarding COVID-19 with Community Care Licensing (CCL.) CCL requires facility staff to be transparent with COVID-19 related information to ensure the safety of staff and residents.

Administrator discussed the various hours employees work. It was discussed that it is important to ensure Labor laws are followed at the facility.

Per office meeting on 8/14/2021 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 staff schedule, handwritten time sheets, and electronic time sheets bi-weekly.

Last electronic time records sheets are from 5/28/2021. Schedules reflect Administrator is passing medications, providing activities, cooking and being a caregiver.

Licensee, Manager and Administrator agree to:
1) Due to ongoing areas of concern to extend Non-Compliance Plan for another year until 8/4/2022.

2) Regional Office referral to TSP

3) Submit electronic time sheets for last two weeks and dates electronic payroll was not functioning to LPA by close of business 8/11/2021.

See LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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: 08/11/2021

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4) 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 to LPA by 8/20/2021.

5) Submit POC documentation from 7/7/2021 Inspection to LPA by 8/20/2021.
POC - Administrator/Licensee will ensure Personnel Records are maintained at the facility. Administrator/Licensee agrees to provide proof of current annual training for staff and self-certification that training is complete by POC due date of 7/21/2021.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

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