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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803987
Report Date: 09/22/2021
Date Signed: 10/04/2021 09:12:31 AM

Document Has Been Signed on 10/04/2021 09:12 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
09/22/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Yolanda DeGuzmanTIME COMPLETED:
05:41 PM
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Licensing Program Analyst (LPA) A. Canela conducted an unannounced pre-licensing inspection on 09/22/2021, for this change of ownership application. LPA met with applicant Yolanda DeGuzman, and Dante Guinto, who will be the Administrator for Heart and Haven Homecare. The facility received a fire clearance approval from the Vallejo Fire Department on 7/7/2021 for a total of 6 Non-ambulatory residents. Applicant will ensure sufficient staffing at all times. The facility is one level home with 6 bedrooms , of which 5 bedrooms may be used for residents, 2 bathrooms, living room, dining room, kitchen, medication room, and garage.

During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance
· Lockable separate cabinets for medications, toxin, and knives.
· All exits were unobstructed
· 6 smoke and 1 carbon monoxide detectors, which were all operational.
· First Aid kit and flashlights for emergency lighting.
· Supply of linens, paper products, and hygiene supplies available.
· Grab bars and non-slip mat in bathroom.
· Fire Extinguisher charged and serviced 06/8/2021
· The water temperature was tested during inspection and LPA observed reading of 105 which is within regulation of 105-120 Degrees F.
· LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for 5 clients.


The Component III Orientation was completed with Applicant along with file review of resident/staff file.


Report continued on LIC809-C for corrections needed prior to licensure
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: HEART AND HAVEN HOMECARE, THE
FACILITY NUMBER: 486803987
VISIT DATE: 09/22/2021
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Pre-licensing is incomplete and the following needs to be corrected:

  • Required furnishings in 4 bedrooms, Bedroom #5 requires a night stand; Bedroom #4 requires a night stand and a lamp, Bedroom #3 and #2 requires a lamp.
  • Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Client personal rights and visitor policy).
  • Bedroom #3's exit door needs to be fixed to prevent air drifting in, and window maintenance or air draft.

  • Bedroom #1 sliding door needs to be cleaned up on edges, or door needs to be replaced.

  • Backyard patio umbrella needs to be replaced or removed and an additional area offered to provide shade. Small metal patio table needs to be cleaned up or removed.


Applicant will need to submit proof of corrections to LPA A. Canela prior to licensure.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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