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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804040
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:44:54 PM

Document Has Been Signed on 03/27/2024 03:44 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
SANTA ROSA RO, 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: 1DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Armelle GbyTIME COMPLETED:
03:55 PM
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LPA Hiratsuka conducted this annual visit.

This facility has a fire clearance for five ambulatory only residents. There is one shared resident and three private resident rooms. The shared resident room has a full private bathroom. There is one full common bathroom. There is an ample supply of nonperishable and perishable food. There is a locked shed in the backyard.

LPA reviewed one resident file and five staff files.

The following shall be updated and submitted to Community Care Licensing Division by April 16, 2024:
-LIC 308 designation of administrative responsibility
-current liability insurance
-LIC 500 facility personnel or staff schedule

No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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