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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803987
Report Date: 11/18/2022
Date Signed: 11/18/2022 07:13:15 PM

Document Has Been Signed on 11/18/2022 07:13 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:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jean AlojadoTIME COMPLETED:
12:50 PM
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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 and Julita Gozos, Administrator was called and arrived towards the end of the inspection. The inspection is focused on the Infection Control procedures and practices of this facility, that is licensed for up to 6 non-ambulatory residents of which 3 may be on Hospice services and no rooms are approved for bedridden.

Upon arrival, LPA observed that facility has Covid posters on the front door. . Once inside the facility, LPA observed that facility has a sign-in for visitors, screening area with PPE . LPA observed that staff were wearing masks during today's visit. LPA conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms, but no paper towels. Facility was a comfortable temperature. Residents are encouraged to wear masks when in the community. Commonly touched surfaces are disinfected daily.
Facility staff have been trained on PPE Facility has submitted their Covid-19 Mitigation Plan and Infection Control. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. PPE is in a location that is stored and accessible to staff. Facility maintains a 30 day supply of medication. Fire extinguisher was charged and last serviced 8/19/2022. Smoke alarms and carbon monoxide are operational.

LPA consulted regarding the backyard left gate latch that is getting tight and will need to be changed or fixed. The dining room sliding door screen handle needs to be repaired and the bottom track cleaned or corrected for the door to slide easy. LPA also requested facility to review if there is a problem with R1s television and that television is located where R1 can properly observe television.

Continue report See LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEART AND HAVEN HOMECARE, THE
FACILITY NUMBER: 486803987
VISIT DATE: 11/18/2022
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LPA went over reporting requirements and reports to be submitted to CCL within 7 days of incident. Facility to meet with the residents to go over food choices. LPA went over prohibited conditions.

LPA requested the following updated records to be submitted to Community Care Licensing by 12/15/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond, if applicable
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of Liability insurance
· Copy Administrator Certificate
· Copy of Admission Agreement


Exit interview conducted with Jean Alojado, current Administrator. LPA will review information sent by facility and do the changes to reflect Jean as the Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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