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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803978
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:33:32 PM

Document Has Been Signed on 10/22/2024 03:33 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/
DIRECTOR:		PASCUA, LESLIE ANNFACILITY TYPE:
735
ADDRESS:137 SUMMERTIME LANETELEPHONE:
(707) 673-4142
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 5CENSUS: 4DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Leslie Ann Pascua, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 10/22/2024, Licensing Program Analyst (LPA) Jill Nakagawa, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Leslie Ann Enriquez (changing name from Pascua), Administrator Certificate # 6056105735, and explained the purpose of the visit.
LPA Nakagawa and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free. Each bathroom to have the necessary grab bars, non-skid flooring, paper towels, soap and trash can. LPA observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. Hot water temperature was measured at 110 degrees F, within the required range. LPA observed two (2) fire extinguishers last serviced on 10/22/2024 and fully charged, smoke detectors, and carbon monoxide detectors checked and functioning throughout the facility. Last fire drill conducted on 08/31/2024. LPA observed the first aid kit to be complete and ready for use.

In the areas toured no immediate health, safety, or personal rights violations were observed. Several topics were discussed.

LPA reviewed a total of four (4) resident files and (4) three (3) staff files which contained all the required documentation.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report left at the facility.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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