486804012-2-10-2022-21-AS-CFES-CBHT4D-20220210132346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:24:04 PM

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:	HAVEN'S HOUSE OF ASSISTED LIVING		FACILITY NUMBER:	486804012
ADMINISTRATOR:	THOMAS, APRIL		FACILITY TYPE:	740
ADDRESS:	2769 BRADBURY WAY		TELEPHONE:	(415) 374-5703
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	4	CENSUS: 0	DATE:	02/10/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee, April Thomas		TIME COMPLETED:	01:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 10:30AM, Licensing Program Analysts (LPAs) Felias and Willis arrived announced to conduct a Pre-Licensing Inspection and met with Applicant April Thomas. LPAs conducted a walk-through of the facility. Facility is a single story house with 5 client rooms, 3 bathrooms and common spaces. Facility also has an apartment in their converted garage which contains a kitchenette and bathroom. Client rooms are furnished per regulation with a bed, lamp, dresser, and bedside table. One small bedroom does not have a chair but Applicant and LPAs discussed ways to reconfigure rooms to accommodate a chair. Bathroom showers have non-skid shower strips and grab bars. There was a locked area for medications and for resident and personnel files. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. The laundry room has a lock to secure toxins and cleaning supplies. Facility backyard has multiple areas for visiting and activities. LPAs did not have a thermometer to check the temperature of the facility water. Facility has a tankless water heater that is maintained at 120 degrees F. LPAs suggested turning water heater down to accommodate for fluctuations in temperature. Exit doors had working alert devices installed. Facility has an exterior surveillance system. LPAs discussed what is needed if the Applicant chooses to have indoor cameras. LPAs discussed having a central area to screen visitors for Covid-19 and to have a thermometer, hand sanitizer, masks, and a sign in log. LPAs will send CCL Covid posters to applicant so they can post them in the facility. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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: HAVEN'S HOUSE OF ASSISTED LIVING	FACILITY NUMBER: 486804012
	VISIT DATE: 02/10/2022

NARRATIVE

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Continued from LIC809

Facility received an approved fire clearance dated October 10, 2021 that allows for four ambulatory clients. LPAs confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage.

Applicant is planning on admitting residents who receive veterans services. LPAs discussed Basic Services with the Applicant to ensure that they and/or their staff are providing care and supervision per regulation regardless of what outside services are provided to the residents.

LPAs and Applicant discussed their Application that indicated they would have four ambulatory clients. Based on LPAs walk-through, some bedrooms are large enough to accommodate a non-ambulatory resident. LPAs requested that Applicant provide an updated sketch indicating which rooms would be designated as non-ambulatory, ambulatory and for staff. CCL will request an updated fire clearance based on the updated sketch. Applicant is still determining how they will use the converted garage and agrees to notify CCL prior to admitting any resident into that apartment.

LPAs confirmed that Applicant receives the most recent Provider Information Notices (PINs) that the department sends out. LPAs will submit information regarding the Guardian to Applicant.

Component III was conducted with Applicant being a new Licensee.

This report was reviewed with applicant and a copy was provided. Application Unit will be notified of visit and once noted items are corrected, Application process will proceed.

No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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