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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804040
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:22:01 PM

Document Has Been Signed on 02/10/2023 02:22 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 CARE HOME LLCFACILITY NUMBER:
486804040
ADMINISTRATOR:GBY, ARMELLE MFACILITY TYPE:
735
ADDRESS:151 FORSYTHIA CTTELEPHONE:
(510) 395-3966
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 0DATE:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Aremelle Gby, LicenseeTIME COMPLETED:
02:35 PM
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On 2/10/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Licensee, Armelle Gby. The facility is a one story home with a fire clearance for 5 ambulatory clients. The facility currently has 0 clients in care at the time of visit. Most recent client had moved out of the facility as of 9/30/2022. Licensee is currently vendored under North Bay Regional Center and is working on finding appropriate referrals for additional clients.

LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the kitchen was found to be last charged on 1/11/2023 at the time of the visit. Smoke and carbon monoxide detectors were inspected and found to be in working order. There is an ample amount of perishable and non-perishable food supply. Licensee will replenish food once clients are readmitted. LPA conducted a sample file review and found staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinet located in the garage and under the kitchen sink found to be secured. There was a supply of hygiene products and paper products available and will be provided to clients when admitted. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets located in client common area and found to be secured.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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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 CARE HOME LLC
FACILITY NUMBER: 486804040
VISIT DATE: 02/10/2023
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LPA measured water at faucets accessible to clients and measured between 119.5 and 119.8 degrees F which is within Title 22 Regulations between 105 and 120 degrees F. A storage shed located in the backyard containing tools, furniture and personal items was found to be secured. Licensee, Armelle Gby's Administrator Certification 6057032735 expires on 8/26/2024.
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Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/24/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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