<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:17:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/26/2023 02:17 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 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:
09/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Leslie Ann PascuaTIME COMPLETED:
02:25 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 ) Jill Nakagawa arrived unannounced at Holy Haven for the purpose of conducting a Case Management - Annual Continuation Inspection. LPA was greeted at the door by Administrator Leslie Ann Pascua and was granted access into the facility.

4 of 4 resident files were reviewed during the Annual Continuation - Case Management inspection and found to be complete with the exception of 1 new resident awaiting missing document, which is expected from another agency within the week. 3 staff files were reviewed and found to be complete. During the staff file review, LPA observed 3 out of 3 staff members have sufficient hours of annual training as outlined in Health and Safety Code 1569.625 (b)(2).

LPA observed that all required postings were in place. All bedrooms had required furnishings. Plumbing issues that were present during prior inspection had been repaired, and all toilets, sinks and showers were operational. Water temperature was within regulation, measuring approximately 116 F.

There were no citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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 1