286803790-12-2-2021-21-AS-KLOZ-C9C4D4-20211202180007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 12/02/2021
Date Signed: 12/02/2021 06:00:25 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: 11	DATE:	12/02/2021
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rhon Franco, Administrator		TIME COMPLETED:	06:15 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	License Program Analyst (LPA) Lopez and Fernandes-Goes arrived unannounced to conduct a continuation annual inspection and non-compliance required visit of the facility that occurred on 11/23/2021. LPAs were welcomed by staff and Administrator Rhon Franco. LPA's toured the facility on 11/23/21 and 12/2/21 and a sample of resident's files and a sample of staff were reviewed. As per LPAs observation, documentation review, and interviews conducted on 11/23/21 and 12/2/21. Facility is being cited for the following: (please see LIC 809 dated 11/23/21 for more information) * Facility maintenance and operation: carpet with stains and fragments (photos taken) bedroom broken plug, cobwebs were observed in resident's R1 room, 3 out of 7 residents' bedroom sinks were clogged Unlocked sharps in kitchen drawer Physician Report for 2 out of 7 need to be updated During today's visit, LPAs reviewed a sample of staff records on 12/2/21 and learned that all facility staff present have received criminal record clearances or exemptions. In addition, LPA observed that 4 out 4 new hired direct care staff has proof of some initial training. Staff S1, S2, S3, S4 were hired between 8/21 & 10/21 however; training on file is insufficient. (see copies, LIC 809-D, confidential name list). Facility also has a staff S4 without proof of 1st aid training. Staff S4 was hired on 9/5/2021. Staff S1 file has no proof of health screening and TB test clearance at this time. (LIC 809-D) Per administrator staff S1 hasn't been able to have health screening and TB test clearance done yet due to health insurance issues. Rhon Franco Administrator Certification # 6046042740 expired on 11/27/2021, per administrator documentation to renew has been submitted. At this time facility has no proof of emergency preparedness staff training and/or disaster drills being conducted at the facility. See LIC 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

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: 12/02/2021

NARRATIVE

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At approximately 3:25 p.m. LPA Lopez followed up on a self-reported incident received by Community Care Licensing (CCL) on 9/22/21 regarding R2 regarding a fall. On 9/20/21 R2 fell on the front porch. Administrator heard R2 fall and immediately went to R2. Administrator observed R2 to appear dizzy. R2 had no injuries observed according to Administrator. R2's doctor and family were notified. Doctor requested for resident to stay in facility on 9/20/21. Doctor followed up during appointment that was scheduled on 9/22/21. R2 was monitored by staff.

Appeal of Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Department is requesting facility to update the following documents and submit to CCLD by 12/10/2021 :

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Liability Insurance
Copy of electronic Time sheets for last 2 weeks.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 2 of 14

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: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 drawer with knives was accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care. Unlocked kitchen draw with sharps were unlocked staff and licensee tried to lock during the visit and weren't able. Facility has residents with dementia.
	POC Due Date: 12/03/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all knives, matches, firearms, and etc that could constitute a danger to residents in care are locked at all times. During visit on 11/23/2021 facility removed all items from unlocked draw. At today's visit facility has repaired the drawer lock and items have been locked as observed. POC Cleared.

Section Cited

Care of Persons with Dementia


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 3 of 14

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: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above due to carpet obseved with stains and fragments, cobwebs in resident rooms and residents' bathroom sinks being flooded which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that facility is clean and in good repair at all times. Licensee to attent to facility items that are in need of repair and/or in need to be clean and submit to CCL by POC date of 12/16/2021.

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 new staff at the facility doesn't have health screening and/or TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reveiwed files, interviewed administrator and learned that staff S1 was hired on 8/14/2021 and hasn't been able to make an appointment to acquire TB test clearance and/or Health screening.
	POC Due Date: 12/16/2021
	Plan of Correction
1 2 3 4	Administrator to ensure that all new staff has a health screening and TB test clearance according with regulations requirement. Facility to submit copy of health screening and TB test results for staff S1 by POC due date of 12/16/21.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 4 of 14

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: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 4 staff initial training requirements which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed files, interview administrator, and staff S1, S2, S3, and S4 have not finished the initial training required by this regulation. Staff was hired between 8/21 and 10/21. At this time staff doesn't have full 40 hrs of training and/or the required hrs for dementia and Postural Support, Hospice, and Restricted conditions.
	POC Due Date: 12/16/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all initial and continue training required by H&S Code 1569.625 will be acquired as required. Facility to submit proof of training as required by POC due date of 12/16/2021 for staff S1, S2, S3, S4.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 5 of 14

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: 12/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 staff proof of first aid which poses/posed a potential health, safety or personal rights risk to persons in care. LPA learned during file review that staff S4 doesn't have proof of 1st aid training. Administrator interviewed staff and at this time facility wasn't able to provide proof.
	POC Due Date: 12/16/2021
	Plan of Correction
1 2 3 4	Facility to ensure that all staff has proof of valid 1st aid training on file to be reviewed by this Department. Facility to submit proof of 1st aid training to CCL by POC date of 12/16/2021.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021

LIC809 (FAS) - (06/04)

Page: 6 of 14