486801899-8-17-2023-21-AS-CFOR-CUSSQ3-20230817140404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801899
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:04:12 PM

Document Has Been Signed on 08/17/2023 02:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	GOLDEN HAVEN CARE HOME II		FACILITY NUMBER:	486801899
ADMINISTRATOR:	LUBUGUIN,ROSALINA		FACILITY TYPE:	740
ADDRESS:	900 MURRE WAY		TELEPHONE:	(707) 421-1386
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Primaeudelyn Rabena, Caregiver		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 8/17/23 at approximately 9:30am, and met with Primaeudelyn Rabena, Caregiver. Administrator Rosalina Lubuguin arrived at approximately 10:15am. Certificate, #6010923740, is current- expires 02/09/2024. LPA observed two caregivers working at the time of arrival. There are currently five (5) residents in care. Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on 06/30/2023. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. All exits were free and clear of obstruction. Fire extinguisher, was last serviced on 2/19/2023 and tagged as required. LPA observed nine (9) smoke alarms and two (2) carbon monoxide detectors, working properly during the inspection. Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 114.9 F, which is within regulation. Medications were stored and locked making them inaccessible to residents. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable for residents in care. Continue on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

Document Has Been Signed on 08/17/2023 02:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN HAVEN CARE HOME II	FACILITY NUMBER: 486801899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a tripping hazard with poles and chairs blocking off an area with wood planks and ladders and buckets which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/31/2023
	Plan of Correction
1 2 3 4	Administrator will remove the poles and chairs and clear the wood/ladders/buckets from the backyard and email photos no later then the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GOLDEN HAVEN CARE HOME II	FACILITY NUMBER: 486801899
	VISIT DATE: 08/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continue from LIC809

There are currently five(5) residents in care. LPA reviewed five(5) of five(5) resident files; All resident files were found to be complete.

LPA reviewed three (3) of three (3) staff files. LPA reviewed staff training. All three (3) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 8/24/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Infection Control Plan-if any changes, as discussed
Copy of Current Liability Insurance
Copy of current Administrator Certificate

During the tour of the facility, the LPA observed poles on small chairs blocking off the patio/deck area of the home, which poses a tripping hazard that has wood planks ladders and buckets accessible to residents in care. There is no railing/fencing.

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.

Exit interview conducted with the Administrator. Appeal rights were provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: 707-588-5053
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4