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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 11/10/2022
Date Signed: 11/10/2022 03:28:13 PM


Document Has Been Signed on 11/10/2022 03:28 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: 11DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Rhon FrancoTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/10/2022 to conduct a required - 1 year inspection. Inspection also functions as legal/non-compliance visit. LPA met with administrator Rhon Franco.

Upon arrival LPA observed visitor sign in sheet with temperature logs and COVID postings at the front entrance. LPA was screened by staff and asked to sign in. LPA toured building and grounds. Facility has resident bedrooms on three floors. Stairwells and elevator are present, bottom two floors have direct access to the outside. Currently there is only one resident on the bottom floor. Dining and common areas are found on the middle floor. LPA and administrator discussed how resident moves between floors. Bathrooms were equipped with necessary grab bars and non-slip mats. LPA and administrator had discussion concerning odor in a resident bedroom. Facility plans to take measures to address it. LPA provided guidance on the importance of regular reassessments if necessary and technical assistance on maintenance/operation.

LPA observed a camera in a resident bedroom. Per administrator, this was purchased and placed by resident family. Facility to submit written documentation regarding the camera and addendum to their plan of operation. LPA observed smoke and carbon monoxide detectors throughout the facility. Toxins were locked and inaccessible under the kitchen sink. LPA tested detectors. Fire extinguishers were charged and current. Disaster drills are conducted quarterly.

LPA inspected food storage area in the kitchen. LPA observed a sufficient amount of perishable and non- perishable food. Facility employs a full time cook. LPA observed lunch service upon arrival as well as snacks offered to residents towards the end of the inspection.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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 2


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: 11/10/2022
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LPA reviewed 4 staff files. All 4 staff had current CPR training. LPA was provided with list of staff training conducted online. LPA provided technical assistance on record keeping for staff training as well as resident record keeping. LPA reviewed 6 resident files. Files contained current physician's reports, admission agreements, needs/services plans, initial appraisals, and medication lists. LPA stressed the importance of reassessments and adjusting needs/services plan as necessary.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 500 Personnel Report
LIC 308 Designation of Facility Responsibility
LIC 9020 Resident Roster
Evidence of Liability Insurance
Admin Certificate
Waiver Request for Camera
Addendum to Plan of Operation

Exit interview conducted with administrator, Rhon Franco and a copy of this report emailed to 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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2