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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 09/25/2020
Date Signed: 09/30/2020 04:16:53 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 16DATE:
09/25/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 PM
MET WITH:Rhon FrancoTIME COMPLETED:
10:45 PM
NARRATIVE
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On 9/25/2020 Licensing Program Analyst (LPA) Elliott conducted a case management tele visit with Administrator Rhon Franco. The purpose of today’s tele visit was to deliver citations related to retaining a resident with a prohibited condition.

Administrator made LPA aware on 8/24/2020 "before they evacuated Rose Haven R1 had heel blisters (one on each foot) and one was open (right heel) but the staff didn't notice it until they got to Oakwood. R1 was put on home health two days ago." LPA requested documentation for blisters, any Home Health notes and Home Health Contact Information. LPA received Home Health Documentation from Home Health Agency on 9/14/2020. Home Health Assessment for R1 dated 8/22/2020 reflects Pressure Ulcer of right heel, unstageable and Pressure Ulcer of left heel, unstageable. Facility did not notify CCL regarding prohibited condition. Manager acknowledged R1 was in their care and knew unstageable was a prohibited condition on 9/16/2020. Facility did not notify Community Care Licensing (CCL) they were retaining a resident with a prohibited condition. R1's new Home Health Agency's Home Health and Certification and Plan of Care signed 9/3/2020 reflects consistent diagnoses. LPA informed facility on 9/15/2020 an unstageable wound is considered a prohibited condition, and requested an exception be submitted for R1 to stay at the facility to be reviewed by the Department. LPA also submitted applicable regulations. Exception request is under review.

LPA determined facility kept R1 in care with a prohibited condition and did not notify CCL per regulation. Facility is on a Non-Compliance Plan and Technical Support Program (TSP) is active in the facility.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and 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. Appeal rights given.

(See 809-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ROSE HAVEN LLC
FACILITY NUMBER: 286803790
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2020
Section Cited

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87615(a)(1)Prohibited Health Conditions
Residents with prohibited conditions shall not be admitted or retained. This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review CCL learned that facility retained R1 who had unstageable pressure ulcers, a Prohibited Condition. This is an immediate risk to the health safety and personal rights to residents in care.
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 with all staff. Licensee agrees to schedule training by POC due date of 9/28/2020. Updated policy and procedures and proof of training including trainer, topics, date/time spent, & attendees is to be submitted to CCL by 10/12/2020. Licensee also agrees to update all relevant documentation for R1 and submit to LPA by 10/12/2020.
Type B
10/12/2020
Section Cited

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87211 Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports..(1)A written report shall be submitted to the licensing agency…within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review an incident report was not sent into CCL when R1 had prohibited condition. This is a potential risk to the health, safety and personal rights of 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) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2020
LIC809 (FAS) - (06/04)
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