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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804012
Report Date: 07/07/2023
Date Signed: 09/08/2023 04:22:43 PM


Document Has Been Signed on 09/08/2023 04:22 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: 4DATE:
07/07/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:April ThomasTIME COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced at Haven's House of Assisted Living for the purpose of conducting a Case Management inspection regarding a recently submitted application for an increase of capacity from 4 residents to 5 residents. Community Care Licensing received approval from the Fairfield Fire department for the increase of capacity to 5 Non-ambulatory residents. The facility has an approval for 2 of the residents to receive Hospice services and no approval for bedridden residents.

LPA toured the facility and the facility is now approved for the increase of capacity to 5 non-ambulatory residents.
LPA consulted regarding informational Pins and infection control plan of operation being updated if applicable.


No citations issued during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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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