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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 09/12/2023
Date Signed: 10/25/2023 09:09:46 AM

Document Has Been Signed on 10/25/2023 09:09 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: 4DATE:
09/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Leslie Ann Pascua, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility unannounced for the purpose of conducting a required -1 year annual visit at approximately 10:05 AM on 9/12/23. There was one staff at the facility at the time of inspection. Two residents were at Day Program, one was at the facility doing crafts and one was visiting family. Staff called for Administrator, who arrived within 10 minutes.

LPA toured the building and found it to be clean and well organized. One toilet was currently out of order, but a plumbing repair order had been submitted and there are two other toilets available for resident and staff use. The facility exits and walkways were found to be unobstructed. Two fire extinguishers were last serviced 08/01/2023. Carbon monoxide and Smoke detectors were tested and appeared to be operational. Staff test detectors monthly during their fire drills. LPA observed the 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 outdoor area was clean and had a nice seating area for residents to play board games in the evenings, when it is cooler and shady.

LPA reviewed requirements for Employee and Resident files with Administrator.
LPA will continue Annual Inspection at a later date.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023
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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