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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:44:52 AM


Document Has Been Signed on 09/20/2024 11:44 AM - 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: 0DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Krissia SegoviaTIME COMPLETED:
12:00 PM
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit to ensure there are no residents present in the facility. Upon arrival, LPA observed the doors to be locked and no staff present in the facility. LPA walked around the building and observed rooms within sight were vacant and no one was present. LPA gained the attention of Caregiver Krissia Segovia who resides in the adjacent building. Krissia provided LPA with text messages to the families of residents, alerting them of the issue with the fire sprinkler system and requesting they come and assist in the moving of residents. Licensee was not present at the facility during this visit. Krissia informed LPA that 7 of 10 residents were relocated to the facility in Vallejo, owned by Licensee. Three of ten residents returned to their families. At approximately 11:35AM, LPA toured the building and observed resident belongings but there were no residents present.

No citations issued during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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