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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:07:56 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
08/15/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240815171825
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:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Krissia SegoviaTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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PERSONAL RIGHTS -RESIDENT NOT PROVIDED PRIVACY
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst's (LPA's) Tony Loera and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA's met with Administrator Rose Mahawa, toured the building, interviewed staff and reviewed records. Based on interviews conducted, LPA's were informed there was an incident when staff were assisting a resident in the shower and the door was not closed. Visitors came into the building and witnessed the resident in the shower. 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 XXXX 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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 2
Control Number 21-AS-20240815171825
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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
HSC
1569.269(a)(2)
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1569.269 Enumerated rights; severability:(2)To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance. This requirement is not
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Licensee shall schedule training for all staff regarding personal rights and send date of training to LPA by POC date of 8/23/2024. Evidence of completed training shall be submitted to CCL by POC date of 09/20/2024
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met as evidenced by: Based on interviews conducted, Licensee did not ensure residents privacy was maintained during personal care. This poses an immediate Personal rights risks to residents.
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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: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
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