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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:14:01 PM


Document Has Been Signed on 11/07/2023 12:14 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: 5DATE:
11/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Nathaniel Sherman, Lead StaffTIME COMPLETED:
12:25 PM
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On 11/7/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management and was greeted by Lead Staff, Nathaniel Sherman. The visit is to gather additional documentation for resident (R1) confirming that they have been admitted to the facility as a resident. LPA Tobola received copies of R1's Admissions Agreement and Physician's Report.

LPA Tobola confirmed R1 has now been admitted to the facility as a resident. LPA requested for R1's updated Appraisal or Needs & Service Plan to be submitted to CCLD by due date 11/9/2023. In addition, LPA obtained the change of capacity fee from the Administrator to complete the fire clearance inspection process that has been pending.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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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