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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 03/27/2023
Date Signed: 03/27/2023 11:43:25 AM


Document Has Been Signed on 03/27/2023 11:43 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 LIVINGFACILITY NUMBER:
486804012
ADMINISTRATOR:THOMAS, APRILFACILITY TYPE:
740
ADDRESS:2769 BRADBURY WAYTELEPHONE:
(415) 374-5703
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY:4CENSUS: 1DATE:
03/27/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, April ThomasTIME COMPLETED:
12:00 PM
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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 Plan of Correction (POC) inspection. LPA was greeted at the door by Administrator, April Thomas, and was granted access into the facility.

During the Plan of Correction (POC) inspection, LPA reviewed the background clearance associations for the facility that reflected staff members being associated to the facility. POC is fulfilled. LPA interviewed the Administrator regarding future compliance of this regulation.

No deficiencies were cited during today's POC inspection. Exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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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