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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 10/19/2023
Date Signed: 10/19/2023 12:43:00 PM


Document Has Been Signed on 10/19/2023 12:43 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:HAVEN'S HOUSE OF ASSISTED LIVINGFACILITY NUMBER:
486804012
ADMINISTRATOR:THOMAS, APRILFACILITY TYPE:
740
ADDRESS:2769 BRADBURY WAYTELEPHONE:
(415) 374-5703
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:4CENSUS: 4DATE:
10/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:April Thomas, LicenseeTIME COMPLETED:
01:00 PM
NARRATIVE
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On 10/19/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management and was greeted by Licensee, April Thomas. The Department was informed that an individual (I1) was wanting to be associated to the facility as a staff member. Previously I1 had an action against them by the Department and was not to reside, work, live in a CCL facility. The terms of the Accusation, Decision and Order were effective from December 11, 2006 for two years.

LPA was informed that (I1) resides at the facility and does provide some services as a staff member. However, I1 does not provide any caregiving duties. I1 resides at the facility due to health concerns and is provided care by Licensee. Licensee has agreed that I1 will be considered a resident and will be in compliance with Title 22 Regulations regarding care and supervision.

**Immediate Civil Penalty assessed in the amount of $500 due to caregiver background clearance violation.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
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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Document Has Been Signed on 10/19/2023 12:43 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2023
Section Cited
CCR
87355(e)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This was not met as evidence by:**
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Licensee agrees to submitt in writing; a plan to ensure I1 is considered a resident and provide all documents required per regulation (admission agreement, 602, needs/service etc) by POC date 10/20/2023.
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Based on record review and interview with Licensee, the facility did not comply with the section cited above in 1 out of 1 individuals (I1) without proof of background clearance or association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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In addition, Licensee completed an updated LIC200 for increase in capacity and provided to CCLD.

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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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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