486803978-10-19-2022-21-AS-KWAS-CKCUER-20221019153134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:32:35 PM

Document Has Been Signed on 10/19/2022 03:32 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	HOLY HAVEN 1		FACILITY NUMBER:	486803978
ADMINISTRATOR:	PASCUA, LESLIE ANN		FACILITY TYPE:	735
ADDRESS:	137 SUMMERTIME LANE		TELEPHONE:	(707) 673-4142
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY: 5		CENSUS: 1	DATE:	10/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Leslie Ann Pascua		TIME COMPLETED:	03:45 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) Katrina Walters arrived at the facility unannounced for the purpose of conducting a required -1 year annual visit. Upon arriving at the facility LPA rang the doorbell and knocked on the door multiple times. LPA did not observe staff in the backyard and staff did not come to the front door. LPA called the facility phone number, and left a VM. LPA spoke with Licensee, Leslie Ann Pascua (LP) at 1:17 PM. LP confirmed there was a client in the facility. LP stated that a staff is present at the facility with client. LPA requested that staff open the door to allow LPA to enter the facility. LP stated they would call staff, and return LPA's call. LP called LPA again at 1:22 PM and confirmed staff left the client by themselves. LP arrived at the facility at 1:32 and granted LPA access into the facility. LPA toured the buildings and grounds starting at 1:40 pm and the facility was found to be clean and in good repair. The facility exits and walkways were found to be unobstructed. Fire extinguisher was last serviced 8/26/22. Carbon and Smoke detectors were tested and appeared to be operational. LPA observed the client bathroom and kitchen was sanitary and in good repair. Perishable and non-perishable foods met the required minimum with a 7 day supply of non-perishable foods. Medications were centrally stored and locked. The facility has submitted an infection control plan that was approved by community care licensing. Facility has designated an area for visitors to sign in and have their temperature taken prior to entering the facility. Signs are posted at the entrance and throughout the facility to promote droplet precaution. LPA observed that the facility has at least a 30 day supply of gloves and disposable mask. In addition, LP will gather disposable gowns in the event of an outbreak. continued on LIC 809 C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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 3

Document Has Been Signed on 10/19/2022 03:32 PM - It Cannot Be Edited

Created By: Katrina Walters On 10/19/2022 at 03:07 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HOLY HAVEN 1	FACILITY NUMBER: 486803978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80078(a)

80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interviews the facility did not comply with the section cited above due to client being left without care and supervision which poses an immediate health, safety or personal rights risk to persons in care. **civil penalty issued in the amount of $500
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Administrator/Licensee to send LPA an updated LIC 500 with schedule showing when and which staff will be present while clients are in the facility.

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:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Katrina Walters

LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HOLY HAVEN 1	FACILITY NUMBER: 486803978
	VISIT DATE: 10/19/2022

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

LPA reviewed resident files with Administrator. During record review LPA learned that resident did not have the following completed documents: medical assessment, mental health intake and needs and service plan. Licensee will ensure that client records are current and send copies to LPA by 11/01/22

Deficiencies were observed on July 15, 2021, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil penalty assessed during todays Required 1-year inspection for the amount of $500. Appeal rights given to the Administrator. A copy of this report was signed and given to the Administrator, Leslie Ann Pascua.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3