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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804040
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:30:16 PM

Document Has Been Signed on 03/12/2025 04:30 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/
DIRECTOR:		GBY, ARMELLE MFACILITY TYPE:
735
ADDRESS:151 FORSYTHIA CTTELEPHONE:
(510) 395-3966
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 1DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Armelle Gby, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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At approximately 1:45 PM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year inspection. There was no one at the facility when the LPA arrived. Administrator Armelle Gby arrived at 2:45 PM. Haven Care Home, LLC is Licensed as an Adult Residential Facility (ARF). The facility is a single story ranch house. The facility has an approved fire clearance for five (5) ambulatory Clients between the ages of eighteen (18) and fifty-nine (59). Upon arrival, LPA was informed that there is one (1) client in care. The client was at work during the Inspection. At approximately 2:55 PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 3:10 PM, LPA toured the facility with Administrator Gby. All exits were clear and unobstructed. The one (1) fire extinguisher was last serviced and tagged on 1/3/2025. Food supply was sufficient. The facility is sufficiently lighted. LPA inspected three (3) client bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 2/10/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HAVEN CARE HOME LLC
FACILITY NUMBER: 486804040
VISIT DATE: 03/12/2025
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...Continued from 809

At approximately 3:45 PM, LPA reviewed one (1) client file. One (1) of one (1) client file was observed to be well organized and thorough with all required documentation. LPA reviewed two (2) staff files. All staff files were observed to be well organized with all required documentation including First Aid and CPR certification, education and proper training documentation. LPA spot checked Medication for one (1) client. LPA observed all medications to be centrally stored, secure and with proper documentation. Client’s monies for personal and incidental (P&I) items were spot checked and observed to match the P&I log.

Armelle Gby's Administrator Certification 7023170735 is current with an expiration date of 8/26/2026.

LPA requested the following documents be submitted to Community Care Licensing by 4/12/2025:



LIC 500 Personnel Report
LIC 308 Designation of Responsibility
LIC 610D Emergency Disaster Plan

No deficiencies cited during today's visit.

Exit interview conducted. Copy of report discussed and provided to Administrator Gby. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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