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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804012
Report Date: 04/10/2023
Date Signed: 04/10/2023 10:27:26 AM

Substantiated


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
03/09/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230309102326
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:
04/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Licensee is accepting residents with a higher level of care needs.
Facility does not have proper fire safety precautions for bedridden residents in care.
Staff do not administer medications to resident(s) according to physician's instructions.
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 reviewed staff records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges Licensee is accepting residents with a higher level of care needs and facility does not have proper fire safety precautions for bedridden residents in care. During the course of the investigation, LPA could not review resident records as the facility did not retain resident records during intake of the resident.

(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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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-20230309102326
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: 04/10/2023
NARRATIVE
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Furthermore, during interviews with an outside provider, it was disclosed to the LPA that the resident was bedridden which requires a higher level of care needs (See LIC 9099D). LPA reviewed the STD 850 Fire Clearance and observed that the facility is Fire Clearance approved for 4 residents that are Non-Ambulatory and 0 bedridden residents. Facility is not licensed to care for residents that are Bedridden (See LIC 9099D).

Complaint alleges that staff do not administer medications to resident(s) according to physician’s instructions. LPA could not review the Medication Assessment Record (MAR) for Resident #1 because the facility did not retain the MAR for Resident #1 (See LIC 9099D). Furthermore, during an interview conducted on March 27, 2023 (See LIC 812-Interview-Administrator) with the Administrator, LPA learned that the facility did not retain an LIC 602 and the MAR for Resident #1.

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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20230309102326
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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2023
Section Cited
CCR
87459(a)(4)
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87459(a): The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:

(4) Transferring, including the need for assistance in moving in and out of a bed or chair.

This requirement was not met as evidenced by:
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Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.
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Based on interviews that were conducted, resident was bedridden which requires a higher level of care for the resident that was in placement. Facility is licensed to retain 4 residents that are Non-Ambulatory which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.
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Type A
04/11/2023
Section Cited
CCR
87202(a)(2)
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87202(a): All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons
This requirement was not met as evidenced by:
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Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.
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Based on a review of the STD 850 and an interview with an outside provider, facility retained a resident that was bedridden. Facility is currently Fire Clearance approved for 4 Non-Ambulatory residents which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.
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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: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20230309102326
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: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
87506(a)
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87506(a): The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement was not met as evidenced by:
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Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.
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During the investigation, facility did not retain resident records which included the Medication Assessment Record (MAR) that documents medication administration. This is a potential health, safety and personal rights risk to the resident(s) in care.
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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: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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
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
03/09/2023 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20230309102326

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:
04/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, April ThomasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not adequately trained.
Staff did not seek medical assistance for resident in a timely manner.
Staff did not respond to resident’s request for assistance in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 reviewed staff records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges that staff are not adequately trained. During the course of the investigation, LPA reviewed staff training for the Administrator who was the only one employed during Resident #1’s tenure at the facility, LPA learned that the Administrator had sufficient amount of training. LPA could not prove or disprove that the Administrator was not adequately trained.

(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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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-20230309102326
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: 04/10/2023
NARRATIVE
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Complaint alleges that staff did not seek medical assistance for residents in a timely manner. During the course of the investigation, LPA conducted interviews and learned that the Responsible Party was responsible for coordinating medical appointments which was canceled and was not rescheduled by the Responsible Party. Furthermore, LPA also learned that the residents ride on the day in question was canceled and that no notification was sent to the Administrator of the cancelation. Administrator coordinated a ride via ambulance to get Medical Assistance in a timely manner.

Complaint alleges that staff do not respond to resident’s request for assistance in a timely manner. During the course of the investigation, LPA conducted interviews and could not prove or disprove that the facility staff do not respond to resident’s request for assistance in a timely manner.

A finding that the complaint allegations of Staff are not adequately trained, Staff did not seek medical assistance for resident in a timely manner and staff did not respond to resident’s request for assistance in a timely manner are unsubstantiated meaning that although the allegation 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 allegations are 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: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6