486803987-10-20-2021-21-AS-ACAA-C7YPMP-20211020112638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803987
Report Date: 10/19/2021
Date Signed: 10/20/2021 11:26:42 AM

Document Has Been Signed on 10/20/2021 11:26 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, THE		FACILITY NUMBER:	486803987
ADMINISTRATOR:	GUINTO, DANTE		FACILITY TYPE:	740
ADDRESS:	1442 GRANADA STREET		TELEPHONE:	(707) 651-9299
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY: 6		CENSUS: 5	DATE:	10/19/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Dante Guinto, Administrator		TIME COMPLETED:	03:50 PM

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Licensing Program Analyst (LPA) A. Canela conducted an unannounced pre-licensing follow up inspection, for this change of ownership application. LPA met with applicant Yolanda DeGuzman, and Dante Guinto on 9/22/2021 and corrections were requested. LPA received pictures with several corrections and returned to confirm all corrections that were recommended were made. LPA met with Administrator, Dante Guinto and left a message for applicant Yolanda DeGuzman to notify her of the visit. 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 to meet the needs of residents in care. 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 corrections:

Required furnishings such as night stands and lamps are available in all bedrooms.
Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Resident personal rights and visitor policy).
Bedroom #3's exit door has been repaired and LPA did not notice any air draft.
Bedroom #1 sliding door was cleaned up and has no sharp edges.
Backyard has a new patio umbrella, table and chairs.

LPA reminded applicant and administrator of requirements regarding daily planned activities; at least a minimum of 2 day supply of perishable and 7 day supply of non-perishable food necessary for the amount of residents in care. Menu planning, staff yearly training and ensuring staff are aware of residents health condition, assistance with daily living activities and any dietary restrictions for residents.
The Component III Orientation was completed with Applicant on 9/22/2021.

Additional corrections needed prior to licensure:

Kitchen sink cabinet and dining room screen will need to be repaired or replaced. Cleaning of kitchen cabinets, facility floor trims and main hallway bathroom.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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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