486804012-1-20-2023-21-AS-FSAI-CN9R2T-20230120113851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 01/20/2023
Date Signed: 01/20/2023 11:39:08 AM

Document Has Been Signed on 01/20/2023 11:39 AM - 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 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: 1	DATE:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, April Thomas		TIME COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Haven's House of Assisted Living for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Administrator, April Thomas, and was granted access into the facility. During the inspection process, LPA observed a resident with Dementia based on review of the LIC 602. However, the facility is only licensed to serve residents that are elderly (See LIC 9102). Administrator will contact the Centralized Applications Bureau Unit and then submit a Dementia Program Plan of Operation to the LPA assigned to the facility. LPA and Administrator toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to have no tag. Administrator indicated that they will be getting a new fire extinguisher today (See LIC 9102). All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in 2 of 2 residents bathroom measured at 116 degrees, within acceptable range of 105 to 120 degrees F. Water temperature in the staff bathroom also measured at 115 degrees and is within acceptable range of 105 to 120 degrees. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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: 01/20/2023

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE which is stored in the hallway closet closest to the bedrooms. Administrator has not been N95 Fit tested, and will be in the process of obtaining N95 Fit testing.

LPA requested the following documents to be sent by January 27, 2023:

Dementia Program Plan of Operation
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610D)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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