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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803790
Report Date: 03/05/2021
Date Signed: 03/24/2021 08:34:06 AM

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: 7DATE:
03/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 PM
MET WITH:Rose MahawarTIME COMPLETED:
11:30 PM
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Licensing Program Analyst (LPA) Angela Elliott and Licensing Program Manager (LPM) Bethany Moellers conducted a case management tele-visit with Rose Mahawar, Manager. This purpose of this case management is follow-up on R1’s AWOL incidents. It is being conducted vis tele-visit due to COVID -19 precautions.

CCL received incident report on 1/12/2021 for incident occurring on 1/3/2021 where R1 went outside of the facility fell down the ramp and sustained a head injury. While gathering information for this incident Rhon Franco, Administrator informed LPA R1 had another incident where they left the facility and Rhon had to pick them up from the hospital. CCL did not receive an incident report. Rhon indicated this occurred on 11/10/2020, and Rhon sent the incident report to LPA on 2/25/2021. LPA obtained additional information that R1 left the facility and was brought back by a member of the Sheriff’s Department on 12/27/2020. CCL did not receive an incident report for this incident.

Incident report from 11/10/2020 incident reflected alarm was put on back gate of the facility on 11/12/2020. Rose informed CCL it is not functioning due to technical issues and Rose indicated she is attempting to resolve. Rose agreed to contact Rhon and submit an incident report for R1 leaving the facility on 12/27/2020 by close of business 3/5/2021. Rose indicated she would notify CCL once alarm is functioning.

This is also being investigated in relation to Complaint #21-AS-20201116090028.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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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