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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:43:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240202143325
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: 14DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rose MahawaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Food quality and quantity necessary to meet the needs of the residents is not being served to residents

INVESTIGATION FINDINGS:
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At approximately 8:15 AM, Licensing Program Analyst's (LPA's) Jacqueline Macias and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA's met Administrator Rose Mahawa, toured the building and reviewed records. Based on records reviewed, facility did not have adaquate records to show what food was served to residents. LPA's reviewed the four weeks of menu's the facility rotates through and observed there were only 2 days with changes. Based on interviews conducted, meals at the facility have changed often and the food is not what is listed on the menu. Facility does not have any documentation to show what food items were served. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240202143325

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: 14DATE:
04/09/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rose MahawaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not able to communicate with residents
Facility is not providing appropriate or enough activities for residents
Facility does not have sufficient staff
INVESTIGATION FINDINGS:
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At approximately 8:15 AM, Licensing Program Analyst's (LPA's) Jacqueline Macias and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA's met Administrator Rose Mahawa, toured the building and reviewed records. Based on interviews conducted, LPA's were not able to find evidence to support the allegation that staff are not able to communicate with residents. LPA's were able to speak with staff and understanding was clear. LPA's observed activities being conducted during this visit and on a previous visit conducted on 03/06/2024. The activity conducted during this visit was hosted by staff and was age appropirate. During this visit there were 3 caregivers and the Administrator present to provide care to 14 residents. Based on records reviewed, LPA's did not find evidence that showed there were any residents that had special needs that were not being met. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240202143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2024
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240202143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2024
Section Cited
CCR
87555(b)(6)
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87555 General Food Service Requirements:(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file
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Licensee to ensure facility keeps track of meals that are served when they alter from what was planned. Licensee to submit copies of as served menu's to CCL on the date the menu changes for each week
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for at least 30 days. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure facility was documenting as served meals. This poses a potential risk to resident in care.
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beginning on 04/15/2024. Licensee to continue to send as served menus until 06/03/2024.
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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: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4