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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 03/14/2023
Date Signed: 03/14/2023 02:58:43 PM


Document Has Been Signed on 03/14/2023 02:58 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: 1DATE:
03/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, April ThomasTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Haven's House of Assisted Living for the purpose of conducting a Case Management-Deficiencies inspection that resulted from opening a complaint on March 14, 2023.

During the opening of the complaint on March 14, 2023 at approximately 01:00 PM, LPA was greeted at the door by Staff Member, Tyeka Miles who was not background cleared and associated to the facility (See LIC 809 dated for March 14, 2023). Administrator arrived 15 minutes later.

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 additional civil penalties. Civil Penally assessed. 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: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/14/2023 02:58 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: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited

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87355 Criminal Record Clearance

(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
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Licensee shall ensure that ALL staff members are fingerprint cleared and associated to the facility prior to working at the facility.

In addition, LPA shall provide a written summary on how future compliance will be met.
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This requirement was not met as evidenced by:
During the opening of the complaint on March 14, 2023 at approximately 01:00 PM, LPA was greeted at the door by a Staff Member who was not background clearand associated to the facility
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POC due date on March 15, 2023.

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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: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
LIC809 (FAS) - (06/04)
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