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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 09/01/2020
Date Signed: 09/08/2020 09:37:09 AM

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: 16DATE:
09/01/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rhon FrancoTIME COMPLETED:
10:30 AM
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On 9/1/2020 Licensing Program Analyst (LPA) Elliott conducted a virtual case management visit with Administrator Rhon Franco. The purpose of today’s visit was to ensure that the clients were able to safely return to the home after being evacuated as a result of a wildfire in the area. Facility was required to evacuate due to the health and safety risk that the fire presented to clients in the home. Residents were evacuated on 8/19/2020 and on 8/28/2020 the facility got confirmation from Cal-fire that Deer Park was under warning and the mandatory evacuation had been lifted. Facility was re-populated on 8/29/2020. Based on interview with Administrator, there were no incidents directly related to the evacuation or repopulation of the residents and there is no known damage to the property.

A tour of the interior and exterior portions of the facility was conducted. The facility grounds were cleaned up by maintenance workers the same day the facility repopulated. Per Administrator facility staff cleaned residents bedrooms, bathrooms, living room, hallways, stairs, kitchen, and refrigerators prior to repopulation. Administrator stated the facility does not smell like smoke.

LPA observed at least a 2 day supply of perishable and 7 day supply of not perishable foods on hand for 16 residents. LPA observed no visual signs of fire damage, Administrator confirmed the fire was 10 miles away from the facility. LPA had Administrator test hot water which measured at 110 degrees F. Power and all other utilities including phones, and cable were observed to be working, Facility has a sprinkler system and hard wired smoke detectors/carbon monoxide detectors. According to Manager and Administrator, the Fire Marshal inspected the system the early part of this year.

Administrator ensured best practices for PPE usage during relocation. Two residents went with family during the evacuation. One resident will not be returning to the facility. The other resident will be tested for COVID-19 before returning to the facility.
(See 809-C)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020
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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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: 09/01/2020
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Administrator to submit any updates to the disaster/evacuation plan should modifications be made. Administrator also to submit inspection report for sprinklers/smoke detection system at facility. LPA confirmed that Administrator had received a copy of PIN 20-28-ASC (Emergency Resident Transfers During the Coronavirus Disease (COVID-19) Pandemic) for reference. LPA indicated a copy of PIN 20-28-ASC would be e-mailed to Administrator as well.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2020
LIC809 (FAS) - (06/04)
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