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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 02/08/2022
Date Signed: 02/08/2022 02:51:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 10DATE:
02/08/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Rhon FrancoTIME COMPLETED:
03:05 PM
NARRATIVE
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At approximately 08:45AM, Licensing Program Analyst's (LPA's) Felias and Arnhold arrived at this facility unannounced, to conduct a case management Legal/Non-compliance inspection. This visit is to follow up on the office meeting that was held to review concerns on 4/14/2021. LPA's were met by Administrator Rhon Franco. There was a small table at the entrance where visitors are screened prior to entry. Administrator and LPA's toured the facility, including food storage areas, medication room and staff areas. LPA's observed 1 of the rooms used by staff was unsecured and contained 2 bottles of over the counter vitamins that were not secure. ***A civil penalty is being issued in the amount of $250 for this repeated violation within the last 12 months.*** LPA's discussed the need to ensure staff rooms are secure to prevent situations like this. The facility was clean and in good repair. Resident rooms and hallways had no discernible odors. Food storage areas on the lower floor showed evidence of rodent activity. LPA's were informed a monthly contract has been established with a pest control company to reduce the rodent issue. LPA's observed food safe rodent traps around the area to assist with the reduction of the rodent population. Food items were sealed against pests and to prevent contamination. During the inspection of the medication room, LPA's discussed with Administrator the facility procedures for what staff should do when a resident refuses medication. LPA's requested that Administrator organize a training for staff to ensure they understand when such incidents are to be reported.
During this inspection, LPA's observed staff providing activities for the residents. Residents appeared to be engaged with the activities.
During this inspection, LPA's followed up on an incident report that was submitted on 01/03/2022. Resident was found on the floor of their room at approximately 1:00AM, then assisted back into bed. At approximately 06:00AM, resident was found on the floor of their room again, then assisted to breakfast. Facility contacted responsible person at approximately 7:00AM to report the incident. Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ROSE HAVEN LLC
FACILITY NUMBER: 286803790
VISIT DATE: 02/08/2022
NARRATIVE
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Responsible party contacted the physician and scheduled an appointment. LPA's discussed with Administrator the procedures of the facility for contacting emergency personnel to assist residents.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
Page: 3 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROSE HAVEN LLC
FACILITY NUMBER: 286803790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited

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The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins...and disinfectants. This requirement was not met as
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evidenced by: Based on LPA's observations, Staff room was unsecured with vitamins in bottles accessible to residents. This poses a potential health risk to residents in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3