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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 08/26/2022
Date Signed: 08/26/2022 02:55:12 PM


Document Has Been Signed on 08/26/2022 02:55 PM - It Cannot Be Edited

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: 12DATE:
08/26/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Rhon FrancoTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 08/26/2022 at approximately 1:30 PM to conduct a Case Management-Legal/Non-compliance inspection. Upon entry LPA was screened and required to sign in by staff. Administrator was notified and arrived shortly. LPA met with administrator, Rhon Franco.

LPA toured building and grounds with administrator. Facility is a 3 story building. There are a total of 12 residents, 3 of which are on hospice. 2 Residents are housed on a lower level which has an exit that leads outside. Areas of the facility accessible to residents were clean and in good repair. Walkways and exits were free from obstructions. Lower level of facility has had an ongoing pest problem but facility has taken measures to address it. All food is stored on the middle level. LPA observed sufficient perishable and non-perishable foods. Medications were centrally stored and inaccessible to residents. Toxins were secured and inaccessible. Fire extinguishers were last charged on July 21, 2022. Facility has a fire panel. Bedrooms were furnished as required. Bathrooms had necessary grab bars and non-slip mats. Activity schedule was prominently displayed for the entire month.

Facility is transitioning to an electronic chart system to document resident data which includes medication record keeping and notes on activities of daily living. Facility is conducting ongoing monthly training for staff to keep in compliance.

Exit interview conducted with administrator, Rhon Franco and a copy of this report printed for the facility.


No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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