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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803987
Report Date: 11/22/2024
Date Signed: 11/24/2024 11:41:49 PM

Document Has Been Signed on 11/24/2024 11:41 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:HEART AND HAVEN HOMECARE, THEFACILITY NUMBER:
486803987
ADMINISTRATOR/
DIRECTOR:		GUINTO, DANTEFACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:care staff, Lupo Canilao TIME VISIT/
INSPECTION COMPLETED:
03:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, Lupo Canilao. Administrator, Jean Rice was not available. There are currently 3 residents in care with 1 staff at the time of inspection. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 3 of the residents & no approval for bedridden.
LPA toured facility and grounds and observed all required signs posted in common areas. Infection control practices are present. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods. Fire Extinguishers were fully charged, and have proof of service on 8/20/2024. Water temperature in the resident bathroom was tested and found to be at 118 degrees and within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors & grab bars. Resident files were reviewed and R1 & R2 require an updated current medical assessment (LIC602). All three residents did not have a current appraisal needs & service plan. LPA reviewed staff file & S1 did not have proof of required yearly training and CPR/1st Aid certificate is current & expires 5/25/2026.

Licensee/Administrator to submit copies of the below documents by 12/15/2024. · LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Copy of Liability Insurance- & Copy of Administrator Certificate
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health & 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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Document Has Been Signed on 11/24/2024 11:41 PM - It Cannot Be Edited


Created By: Araceli Canela On 11/22/2024 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above in 1 out of 1 staff did not have proof of the required yearly training and or were missing hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Facility to send in proof of staff S1s annual and complete training. Facility to also send in written plan on how they will ensure they stay in compliance and ensure all staff have the rewuired annual training and records kept in file. POC due date 12/20/2022 attention LPA A Canela.
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review, the licensee did not comply with the section cited above in 3 out of 3 resident who did not have proof of an annual appraisal needs and service plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Facility to send in written statement they understand regulation requirements and how they will stay in compliance. Facility to also send proof the reappraisals were conducted and signed by all parties. POC due date 12/20/2024 attention LPA A Canela
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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