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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804012
Report Date: 07/24/2026
Date Signed: 07/24/2026 03:58:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/29/2026 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20260429143325
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:6CENSUS: 6DATE:
07/24/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not meet resident care needs.
Facility did not maintain adequate staff.
Facility did not seek timely medical care.
INVESTIGATION FINDINGS:
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At approximately 09:30 AM, Licensing Program Manager (LPM) Victoria Bertozzi and Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, April Thomas.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “- Facility did not meet resident care needs, Facility did not maintain adequate staff, and Facility did not seek timely medical care.”

The complaint alleged that the facility was operating with insufficient staffing, resulting in residents not receiving adequate care and supervision. The Reporting Party (RP) stated that there was only staff member caring for seven residents, including a resident who required a two-person assist with a Hoyer lift. RP further alleged that a resident R2 sustained injuries from a fall was not provided timely medical care.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
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 6
Control Number 21-AS-20260429143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAVEN'S HOUSE OF ASSISTED LIVING
FACILITY NUMBER: 486804012
VISIT DATE: 07/24/2026
NARRATIVE
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Continued LIC9099-A page...

Facility did not administer resident medication as prescribed –
The complaint alleged that the facility resident records were falsified, and prescribed medication was not refilled as requested.
During the investigation, the Administrator stated that the resident refused to attend a scheduled physician's appointment. Record review confirmed that Resident R1 had a prescription for the medication in question. Resident R1 stated that the facility failed to schedule the physician's appointment; however, LPA did not obtain sufficient evidence to verify that the facility failed to administer the resident's medication as prescribed. Therefore, the allegation could not be substantiated.

A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 21-AS-20260429143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAVEN'S HOUSE OF ASSISTED LIVING
FACILITY NUMBER: 486804012
VISIT DATE: 07/24/2026
NARRATIVE
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Continued from LIC9099 page...

Facility did not maintain adequate staff –
During the initial investigation, LPA observed one staff member on duty while the facility was caring for six residents, including two residents who required two-person assistance with Hoyer lift transfers. The Administrator confirmed that only one staff member was present during portions of the day and that additional assistance was not available until later in the evening. Based on interviews and observations, the facility failed to maintain sufficient staff to meet the care and supervision needs of the residents.
Based on interviews, record review, and observations, the allegation is Substantiated.
Facility did not seek timely medical care –
Per record review of the facility's incident report dated 05/04/2026 indicated that Resident R2 sustained a fall on 04/26/2026. The facility did not seek immediate medical evaluation following the incident. Instead, per the special incident report, the hospice nurse was contacted the following day, and a physician's appointment was scheduled for 05/06/2026. During the investigation, LPA also obtained photographs documenting visible bruising sustained by R2. Based on the available evidence, the facility failed to seek timely medical care for Resident R2 following the fall. Based on interviews, record review, and observations, the allegation is Substantiated.
Facility did not meet resident care needs –
LPA observed that two residents required two-person assistance with Hoyer lift transfers. Due to insufficient staffing, the facility was unable to consistently provide the level of assistance necessary to safely meet residents' care and supervision needs. Additionally, resident interviews indicated concerns regarding lack of the quality of care provided. Based on observations, interviews, and record review, the allegation is substantiated.
Based on observations, interviews, and record review, the allegations are substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/29/2026 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20260429143325

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:6CENSUS: 6DATE:
07/24/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility is over capacity.
Facility did not administer resident medication as prescribed.
INVESTIGATION FINDINGS:
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At approximately 09:30 AM, Licensing Program Manager (LPM) Victoria Bertozzi and Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, April Thomas.

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Facility is over capacity. and facility did not administer resident medication as prescribed”

Facility is over capacity –
The complaint alleged that the facility is over capacity; LPA reviewed the facility resident roster and, during the initial visit, was unable to determine that the facility exceeded its licensed capacity. Although the allegation was investigated, there was insufficient evidence to support that the facility was operating over capacity. Based on interviews and record review, the allegation is unsubstantiated.
Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20260429143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 07/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2026
Section Cited
CCR
87705(c)(4)
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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's ... care needs as identified... This requirement is not met as evidenced by:
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Licensee has hired at least two additional staff. Licensee agrees to provide proof of training and an LIC 500 showing sufficient staffing to ensure staffing is adequate to meet residents needs during the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.
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Based on LPAs observation and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a immdadiate health and safety risk to residents in care.
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Type A
07/25/2026
Section Cited
CCR
87654(g)
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87465(g) Incidental Medical and Dental Care Services - 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by:
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Licensee agrees to hold an in-service training with all staff regarding policy and procedures for seeking medical attention in a timely manner as incidents and/or observations arise. Proof of training to be provided to CCL during the in-person meeting at the Santa Rosa Regional Office on Monday,
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Based on LPA observation, interviews and record review it was determined that staff failed to seek medical attention in a timely manner for R3 which poses a potential risk to the health, safety, and personal rights to residents in care.
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July 27, 2026.
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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20260429143325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 07/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2026
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident care needs. This requirement is not met as evidenced by:
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Licensee agrees to ensure facility has sufficient staff to meet the needs of residents in care. Licensee to submit updated LIC500 to show care giving staffing levels needs the residents. LIC500 to be brought in for the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.
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Based on records reviewed, interviews conducted, Licensee did not ensure sufficient staff were present to meet resident needs. This poses an immediate Health and Safety risk to residents.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6