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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804135
Report Date: 12/17/2024
Date Signed: 12/17/2024 09:59:50 AM

Substantiated


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
12/15/2024 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20241215233924
FACILITY NAME:JOSHUA'S HAVENFACILITY NUMBER:
286804135
ADMINISTRATOR:TAMBOT-SUNGA, DEYRAFACILITY TYPE:
735
ADDRESS:236 NEWBURY WAYTELEPHONE:
(650) 892-4572
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY:4CENSUS: 3DATE:
12/17/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kamille NastorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not properly notify of alterations to the facility grounds
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegation. LPA met with staff Kamille Nastor and toured the building. LPA observed a construction project in the garage that is adding 2 additional rooms. A permit for the project was obtained on October 26, 2024, however, the Licensee did not notify the Department of alterations to the building.

Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Kamille and Appeal rights were given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 21-AS-20241215233924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JOSHUA'S HAVEN
FACILITY NUMBER: 286804135
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
80086(a)
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80086 Alterations to Existing Building or New Facilities:(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change. This requirement is not met as evidenced by: Based on observation and record review, Licensee did not notify the Department of
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Licensee shall submit an updated facility sketch when construction is completed. Upon receipt of the facility sketch, a request for an updated fire clearance will be sent to the fire marshal's office. Facility sketch shall be submitted by POC date of 01/17/2025.
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alterations to the garage. This poses a potential Health, Safety or Personal Rights risk to persons 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC9099 (FAS) - (06/04)
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