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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803987
Report Date: 04/14/2022
Date Signed: 04/22/2022 02:06:34 PM

Document Has Been Signed on 04/22/2022 02:06 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:GUINTO, DANTEFACILITY TYPE:
740
ADDRESS:1442 GRANADA STREETTELEPHONE:
(707) 651-9299
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
04/14/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Lupo CanilaoTIME COMPLETED:
06:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Post Licensing Inspection and met with Staff Member Lupo Canilao, Administrator was not present.

Upon arrival, LPA temperature was checked and documented and LPA was asked to sign in. LPA conducted a walk-through of the facility and observed the following: Facility has Covid-19 posters throughout the facility, LPA removed a notice that was observed in the front door that stated the facility required any visitor to be Covid tested prior to entering. LPA observed hand washing signs in the bathroom. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. Staff wear masks while in the facility. Observed staff had mask on during this visit.

LPA observed the facility is not providing any activities and this was confirmed with 2 of 5 residents. Commonly touched surfaces are disinfected daily or as needed.
Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves and hand sanitizer.

Facility failed to have correct or an admission agreement in file for 2 of residents and preadmission medical assessment for resident R2

During today's visit there was no evidence of staff having CPR/1st aid, but facility stated the training was current and will provide proof to LPA Canela.

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, may result in a civil penalty assessment. Appeal rights read and emailed to facility.



citations issued see LIC809-D
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/22/2022 02:06 PM - It Cannot Be Edited


Created By: Araceli Canela On 04/14/2022 at 05:18 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: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection,, interview with staff S1 and LPAs review of residents files in medication room, the licensee did not comply with the section cited above in 1 out of 2 files reviewed for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Facility to send in written plan on how they will ensure they meet regulation and proof pre admission appraisal to LPA A Canela by 4/29/2022.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection,, interview with staff S1 and LPAs review of residents files in medication room, the licensee did not comply with the section cited above in 2 out of 2 files reviewed for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Facility to send in written plan on how they will ensure they meet regulation and proof correct and Admission Agreement for this facility to LPA A Canela by 4/29/2022.
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: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022


LIC809 (FAS) - (06/04)
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