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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:07:14 AM

Unsubstantiated


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
08/14/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240814135726
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:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Theresa Ilagan (TJ)TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident bed was not operational.
Resident rights.
Facility is over medicating resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced, to deliver findings from an investigation into the above allegations. This visit is being conducted at Licensee's facility in Vallejo. LPA met with Facility Manager Theresa Ilagan. LPA spoke with Administrator Rose Mahawar via telephone during this visit. Based on interviews conducted and visual observation, Resident had a bed provided by a medical resource company. The facility has beds available but they are of an older style and only use them in an emergency. The wiring that powers the bed became tangled in the undercarriage of the bed and was broken. The facility contacted the medical resource company to acquire another bed. Based on interviews conducted, LPA was not able to find evidence to support the allegation that residents rights were violated. Based on interviews conducted, the resident was borderline more than the facility could manage and they were having difficulties with the hospital discharging resident back to the facility before they were ready. LPA reviewed medications and did not observe any concerns. The pill count was consistent with the start date, however facility was not using a medication administration record. 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.
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: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
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
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
08/14/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20240814135726

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:
01/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Theresa Ilagan (TJ)TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not follow physician orders for O2.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 10:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced, to deliver findings from an investigation into the above allegation. This visit is being conducted at Licensee's facility in Vallejo. LPA met with Facility Manager Theresa Ilagan. LPA spoke with Administrator Rose Mahawar via telephone during this visit. Based on records reviewed and interviews conducted, resident did not have written orders from a physician regarding the use of Oxygen. The investigation found the only mention of oxygen use was in the skilled nursing notes on the amount the resident was on. There were no orders following the discharge back to the facility.

This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
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 2