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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 11/05/2021
Date Signed: 11/05/2021 11:27:11 AM

Document Has Been Signed on 11/05/2021 11:27 AM - It Cannot Be Edited

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:HOLY HAVEN 1FACILITY NUMBER:
486803978
ADMINISTRATOR:PASCUA, LESLIE ANNFACILITY TYPE:
735
ADDRESS:137 SUMMERTIME LANETELEPHONE:
(707) 673-4142
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: DATE:
11/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Applicant, Leslie PascuaTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Leslie Pascua.

Upon arrival, LPA observed that there were no Covid-19 posters on the front door or inside. LPA was not screened for Covid-19 symptoms. When asked about screening, Applicant indicated that the agency they are currently with does not require screening and posters. Facility currently has two clients placed by that agency. LPA and Applicant toured the inside of the facility and grounds. Facility is a two story residence with four bedrooms, three bathrooms and common areas. The master bedroom is currently being used as a staff room. LPA informed Applicant that the staff room must be locked at all times if items that could be harmful to clients is stored in there. One client room is vacant but is furnished per regulation. Two other rooms are occupied and are furnished. Bathroom shower has non-skid shower floor. LPA confirmed that contents of the facility First Aid Kit were sufficient. Water temperature in bathrooms read at 107 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked cabinet in the kitchen used for centrally stored medications. Files are also stored in the cabinet. Cleaning supplies and toxins will be locked in a cabinet under the kitchen sink, in a downstairs closet and in a locked cabinet in the laundry room. Perishable and non-perishable foods observed per regulation. Emergency food and water is stored in the garage.

LPA observed a camera in the upstairs hallway that appeared to be pointed in the direction of a client's room. Applicant explained the reasoning for the camera. LPA explained that cameras can be a violation of personal rights and they would need to request an exception in order to use the camera.

Facility has a backyard that had a couple items that will need to be removed or stored when not in use. Additionally, facility will need to provide an outdoor seating area for visitation and outdoor activities.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HOLY HAVEN 1
FACILITY NUMBER: 486803978
VISIT DATE: 11/05/2021
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Continued from LIC809

Facility received an approved fire clearance dated June 11, 2021 that allows for five ambulatory clients. Carbon Monoxide detector upstairs and downstairs were tested and operational. Facility has emergency lighting in hallways that double as flashlights.

The following items will need to be corrected prior to licensure:
  • Covid-19 posters including hand washing signs in bathrooms must be posted.
  • Facility must have a screening area at entrance to screen visitors which includes a thermometer and a sign-in sheet with screening questions.
  • A shaded, outdoor seating area
  • All items noted during inspection removed from the backyard
  • Camera removed or an exception request be submitted


Applicant to review PIN 21-40-ASC and PIN 21-44-ASC regarding the most recent visitor and vaccination guidance. LPA and Applicant also discussed the Guardian system for fingerprinting in case staff is hired.

Component III was conducted. LPA has requested pictures of the above items in order to proceed with application process.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2