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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 10/30/2020
Date Signed: 10/30/2020 08:22:32 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200228145042
FACILITY NAME:ROSE HAVEN LLCFACILITY NUMBER:
286803790
ADMINISTRATOR:WAWERU, PETERFACILITY TYPE:
740
ADDRESS:520 SANITARIUM RDTELEPHONE:
(707) 963-3748
CITY:ST HELENASTATE: CAZIP CODE:
94574
CAPACITY:32CENSUS: 15DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rhon FrancoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff do not ensure that the facility is maintained in good repair.
Staff do not meet resident's toileting needs.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, by tele-visit, with Administrator, Rhon Franco for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation staff do not ensure that the facility is maintained in good repair. Interview with S1 indicated Rose Mahawar, Manager bought old vacuums that have been non-functional for over a month. Staff are asked to clean the carpets with a broom. The washer and dryers were bought used and they break down. (Video obtained of R1’s room which had a thick layer of dust on surfaces, cobwebs on the wall and debris on the floor. The bathroom sink and toilet bowl rim had hair stuck to the surface and the toilet bowel had a pronounced brown ring at the surface of the water.) Multiple interviews revealed a designated staff is not cleaning the facility but it is spread amongst staff. Interview with Administrator on 5/26/2020 indicated the staff clean on their down time.

(See 9099-C)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20200228145042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/30/2020
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

There is an allegation staff do not meet resident's toileting needs. Interview with outside party on 3/4/2020 revealed “The wheelchair for R2 had pee in it and R2’s back was wet with urine. Multiple staff interviews reveal residents were either not being taken to the bathroom and left wet for long periods of time. Sample documentation review for eight residents indicated they all need assistance with toileting activities. LPA observed on 2/24/2020 residents sitting on the couch after lunch were not toileted for several hours. Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

(See 9099-D)
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200228145042

FACILITY NAME:ROSE HAVEN LLCFACILITY NUMBER:
286803790
ADMINISTRATOR:WAWERU, PETERFACILITY TYPE:
740
ADDRESS:520 SANITARIUM RDTELEPHONE:
(707) 963-3748
CITY:ST HELENASTATE: CAZIP CODE:
94574
CAPACITY:32CENSUS: 15DATE:
10/30/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rhon FrancoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that resident is adequately fed.
Staff handles residents in a rough manner.
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
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9
10
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12
13
Licensing Program Analyst (LPA) Angela Elliott made contact this date, by televisit, with Administrator, Rhon Franco for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation staff do not ensure that resident is adequately fed. Staff interviews also revealed “I don't like that S3 and S4 move the residents when they really don't finish breakfast. You need to give them time to finish.” Interview with outside party on 5/27/2020 indicated “Some families don’t want the staff to feed clients if they don’t feel like eating, but they get fed no matter what.” There was a lack of consistency in staff interviews about which residents get ensure and when they get ensure. Documentation did not specify parameters for meal replacements. There was no additional information to support the allegation that residents are not being adequately fed, and interviews revealed conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
(See 9099-C)
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20200228145042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/30/2020
NARRATIVE
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There is an allegation staff handles residents in a rough manner. Although complainant alleges newer staff are rougher with the residents, and S5 threw R3 on the couch and every time R3 would cry, LPA did not observe staff being rough with the residents, and was not able to gain any additional information to support the allegation. LPA observed disrespectful comments made by the Manager, Rose Mahawar and will handle on a case management. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20200228145042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/30/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/30/2020
Section Cited
CCR
87625(a)(b)
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87625 (a)(b) Managed Incontinence -The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition in compliance with this regulation as listed in (a) as well as in (b). This requirement has not been met as evidenced by:
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Administrator/Manager to ensure resident incontinent needs are met. Manager/Administrator agrees to submit incontinent care plan for incontinent care, procedures regarding managed incontinence, and facility's plan of future compliance with this regulation by POC due date 11/2/2020.
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Based on LPA interview, observation and record review, residents were not toileted and/or transferred by staff as needed. Licensee/Administrator failed to ensure managed incontinence for residents.as required. This poses an immediate health & safety risk to resident(s) in care.

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Type B
10/30/2020
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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Administrator/Manager agrees to design plan with specific duties of housekeeping with essential working equipment to assist with keeping the facility sanitary for residents, employees and visitors by POC due date of 11/2/2020.
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Based on LPA observation, interview and record review, the Administrator/Manager did not ensure working equipment and staff were available to maintain a clean, safe and sanitary facility environment which 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: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5