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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803987
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:22:55 AM

Unsubstantiated


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
04/04/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240404114856
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: 6DATE:
04/30/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bianca RicasataTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
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5
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9
Facility is not meeting residents needs
INVESTIGATION FINDINGS:
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2
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4
5
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9
10
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13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that the facility has not met R1's care needs in that R1, prior to R1's admittance to a medical facility, had lost weight, refused food and medications, and neglected routine hygiene care. This investigation, based on statements and document reviews, indicates the following: R1 has a history of periodic bouts of self-neglect; On or about 4/25/2024, R1 was admitted to a medical facility; Facility records indicate R1 began refusing medication a few days prior to hospitalization and that a report was made of R1's declining state on 4/25 to this agency and R1's Responsible Person as required by Title Twenty-Two; Facility Administrator called 911 who assessed R1 and determined R1's need for inpatient care; R1's Responsible Person states that the facility staff have provided good care to R1 and that staff have taken appropriate action to assist R1 despite R1's often refusal to accept care. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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