486804012-4-21-2023-21-AS-CMAZ-CRGUPX-20230503154616

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804012
Report Date: 04/21/2023
Date Signed: 04/21/2023 11:03:26 AM

Unsubstantiated

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
04/14/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230414100907

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: 2	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Licensee/Administrator, April Thomas		TIME COMPLETED:	11:13 AM

ALLEGATION(S):

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Licensee did not release resident's personal belongings to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to conduct a complaint investigation regarding the above allegation and met with Licensee, April Smith.

Licensee did not release resident's personal belongings to responsible party - Complaint alleges that personal items including letters, medication and incontinence products were not released to the responsible party after resident moved. Per conversation with Licensee they returned the letters and medication to the Veteran's Association and denied having incotinence products belonging to the the resident.

A finding that the complaint allegation, Licensee did not release resident's personal belongings to responsible party was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited during this inspection

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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