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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 10/30/2020
Date Signed: 01/11/2021 12:46:07 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: 14DATE:
10/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Rhon FrancoTIME COMPLETED:
12:00 PM
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LPA Angela Elliott conducted a tele-visit with Rhon Franco, Administrator to discuss re-population of the majority of facility residents occurring on 10/28/2020 and the final resident coming to facility on 11/29/2020. Facility was evacuated during the recent fires but has since repopulated. Licensing Program Analyst (LPA) Elliott spoke to Rose Mahawar, Manager and Rhon Franco, Administrator about the importance of being able to get a hold of someone at the facility. LPA reviewed discrepancies in schedule with Administrator. Administrator indicated he would update schedule and send to LPA.. Administrator confirmed staffing levels on AM's two staff, PM's two staff, and NOC shift one awake staff and one on call staff (asleep). LPA reviewed assessment documentation for residents.. Administrator confirmed current census of residents they all are only a one person assist. LPA requested additional documentation regarding the altercation between R1 and R2 for further investigation. LPA requested additional documentation for R3's diet plan for further investigation. LPA requested additional documentation for R4 for further investigation. Tele-visit was suspended when unexpected admission arrived at facility and will reconvene later this after noon.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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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