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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:06:38 AM

Document Has Been Signed on 12/09/2022 11:06 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 1DATE:
12/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:StaffTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a Plan of Correction (POC) Case Management visit.

LPA was allowed entry into the facility by staff. Staff was not able to locate PPE. Staff and LPA toured the facility and observations were made. Based on LPA's observation, facility has corrected the deficiencies that were cited on October 19, 2022.

LPA is requesting that Administrator shows proof of a 30 day supply of PPE and that all staff knows where its located.

LPA was unable to obtain staff's signature. A copy of this report and a copy of the proof of correction letter was provided to the Administrator via email.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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