286803790-11-23-2021-21-AS-KLOZ-C933UL-20211123173343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 11/23/2021
Date Signed: 11/23/2021 05:33:52 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:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rose Mahawar, Licensee		TIME COMPLETED:	05:45 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 Analysts (LPAs) Lopez and Fernandes-Goes conducted an unannounced Annual Required – 1 yr. & Non-Compliance Infection Control inspection to this facility and was welcomed by staff 1 (S1) and S2. Staff contacted licensee. Licensee, Rose Mahawar arrived later. Facility has 11 residents. There are two residents under hospice care. LPA Lopez asked licensee if facility has residents with prohibited condition. Licensee stated that facility does not have any residents with prohibited conditions at this moment. LPAs arrived at the facility and had her temperature checked and logged into visitor’s binder. LPA’s toured the facility with S1 until Licensee arrived. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. During facility tour, LPA’s observed different areas of the facility carpet that contained multiple stains, including resident (R1’s) carpet (photos taken). While inspecting resident’s rooms, LPA’s attempted to test water. Facility understands that hot water temperatures must measure degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Sinks in restrooms for R2, R3, R4 and bathroom downstairs near living room flooded while attempting to take water temperature (photos taken). While touring resident’s bedrooms, cobwebs were found in R5’s bedroom and living room. Continue to LIC 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
	VISIT DATE: 11/23/2021

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
26
27
28
29
30
31
32

At 11:26a.m., during tour of the first floor, LPAs observed unlocked bottle of Clorox and a bottle of Laundry Detergent. S2 stated that toxins room was locked and lock was not functioning. S2 immediately locked the toxins in a locked cabinet on the second floor. During the inspection of the facility kitchen, LPA’s observed broken drawers. Sharps in cabinet were observed to be unlocked. The sharps cabinet lock was broken. Licensee put the sharps away in a locked drawer inaccessible to residents in care. LPA’s reviewed a sample of seven resident files. During the review of resident files, LPA’s observed alteration of Physician Report for two out of seven residents. Three out of seven Physician Reports had no signatures.

Fire Extinguisher was found to be last charged on July 2021 at the time of the visit. A sample of Smoke & Carbon monoxide detectors were tested and operational during visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There is a daily activity schedule for residents. There was a supply of cleaners and hygiene products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work.

Residents’ medications are stored and locked in medication room unless resident is able and allowed to dispense and store his/hers own medication. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility. All staff had masks on during this visit. Facility understands that all staff need to be fully vaccinated unless exemption for medical or religious reason is on file. If staff is not fully vaccinated and has an exemption due to medical or religious reasons, staff will need to be tested once a week.

Continue to LIC809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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
	VISIT DATE: 11/23/2021

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
26
27
28
29
30
31
32

In addition, facility is allowing visitors in the facility. LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA met with Licensee, Rose Mahawar regarding concerns that were observed during this visit. This visit will need to be continued at another date when deficiencies and infection control assessment will be conducted.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Licensee, Rose Mahawar, whose signature below confirms receipt of report.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen Lopez	TELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3