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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804012
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:16:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220909160348
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: 0DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not addressing resident’s incontinence needs in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Haven's House of Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by, Licensee/Administrator, April Thomas, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to witnesses. LPA conducted tours of the facility on September 13, 2022 and September 26, 2022.

Complaint alleges that Staff are not addressing resident's incontinence needs in a timely manner. Based on interviews with staff, resident and witnesses; LPA was unable to prove or disprove that the incontinence needs were not being addressed in a timely manner. Furthermore, LPA did conduct a walk through of the facility on September 13, 2022 and found the physical plant and the residents room had no foul odors of incontinence. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220909160348

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: 0DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
3
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5
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9
Staff are monitoring resident via a baby monitor
Staff are not allowing resident to have private conversations and/or visits
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Haven's House of Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by, XXXX, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to witnesses. LPA conducted tours of the facility on September 13, 2022 and September 26, 2022.

Complaint alleges that staff are monitoring resident via a baby monitor. During the opening of the complaint on September 13, 2022, LPA conducted a walk through of the facility and observed an auditory baby monitor in the residents room that is being monitored from the kitchen area by staff (See LIC 812-Observation dated for September 13, 2022). Furthermore, Resident was able to identified where the auditory baby monitor was placed at (See LIC 9099D). Licensee/Administrator removed the baby monitor on September 13, 2022. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220909160348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/05/2022
NARRATIVE
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Complaint alleges that Staff are not allowing resident to have private conversations and/or visits. Based on interviews conducted, observations and placement of the auditory baby monitor in the facility kitchen, the auditory baby monitor is put in a common area of the facility and private conversations and/or visits can be heard by facility staff inside the kitchen at any time (See LIC 9099D).

Deficiencies 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. Exit interview was conducted, and a copy of this report was signed and given to the Licensee/Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20220909160348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1)-Personal Rights of Residents in All Facilities:

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Plan of Correction shall include the removal of the baby monitor.
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This requirement was not met as evidenced by:

LPA observed during the facility tour on September 13, 2022 that a baby monitor was inside the residents room, and was being used to monitor the resident's call for assistance.
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Type B
10/06/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1(a)(11): Personal Rights of Residents in All Facilities :

To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Plan of Correction shall include the removal of the baby monitor.
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This requirement was not met as evidenced by:

The auditory baby monitor was turned on. The receptor is kept in the live-in kitchen area, which can be heard by other facility staff, residents and visitors. This violation presents a potential Personal Rights violation.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220909160348
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/05/2022
NARRATIVE
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LPA conducted a subsequent complaint investigation inspection on September 26, 2022 and learned that the resident has since relocated. LPA conducted an additional walk through on said date and found no evidence to suggest that incontinence needs were not being met.

A finding that the complaint allegation of Staff are not addressing resident’s incontinence needs in a timely manner are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5