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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803987
Report Date: 05/09/2022
Date Signed: 05/09/2022 06:35:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2021 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211223154326
FACILITY NAME:HEART AND HAVEN HOMECARE, THEFACILITY NUMBER:
486803987
ADMINISTRATOR:GUINTO, DANTEFACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Jean RiceTIME COMPLETED:
06:40 PM
ALLEGATION(S):
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Medication is administrated improperly
Medication is not refilled timely
Food quality is poor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings and reviewing additional records regarding the above allegations and met with new Administrator as of today 5/9/2022, Jean Rice.

It was alleged medication is administrated improperly by facility. LPA previously conducted several visits to the facility, made observations, gathered statements and reviewed records. Investigation revealed facility medication administration records indicated resident R1 had received a medication that was to be stopped according to residents after visit summary report.

Continue report see LIC9099- C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20211223154326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEART AND HAVEN HOMECARE, THE
FACILITY NUMBER: 486803987
VISIT DATE: 05/09/2022
NARRATIVE
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In addition, on todays inspection visit, LPA observed a small plastic container cup with several medication that was left in a small table next to resident R2. Staff improperly left the medication there for the resident to take later and did not wait for resident to take it, and there are several residents in the facility including resident R2's room-mate with dementia diagnoses. It was also alleged medication is not refilled timely, records reviewed indicated facility is not properly documenting all medication and some medication is being received late or not filled due to insurance issues and lack of documentation. In addition, it was also alleged food quality is poor. LPA made several visits and although food service has improved, on the visit of 12/29/2021 the facility had several bowls with food not properly stored and items in the freezer had frostbite and packages opened. Based on all of the above the following allegations, Medication is administrated improperly; Medication is not refilled timely and Food quality is poor, the preponderance of evidence standard has been met, therefore the above allegations are found to be all SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, and repeated deficiencies within a 12- month period may result in a civil penalty assessment.

This report was reviewed with Jean Rice and Appeal Rights provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20211223154326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HEART AND HAVEN HOMECARE, THE
FACILITY NUMBER: 486803987
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed
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Facility to send in written plan they understand regulation by POC due date 5/11/2022 and in addition to conduct an internal audit of all residents medication, documented correctly in the centrally stored log, MARS according to residents
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This requirement was not met based on LPAs review of medical records and medication left in the room for resident R2 to take and not observing R2 taking the medication is an immediate risk to the residents in care.
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current medication list.

second plan of medication audit to be completed before 5/18/2022
Type A
05/10/2022
Section Cited
CCR
87555(a)
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87555(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Facility to send in written plan on how they will continue to meet regulation to LPA Canela by POC due date: 5/10/2022
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This requirement was not met, based on LPAs observation of visit 12/29/2021. Food was observed not covered, with open food packages in the freezer with frostbite, possible contamination. Food provided to residents lacked vegetables/greens. This is an immediate risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3