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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804040
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:06:12 PM

Document Has Been Signed on 06/21/2022 04:06 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: 4DATE:
06/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Armelle Gby (Licensee)TIME COMPLETED:
04:21 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Post-Licensing inspection to this facility, and was greeted by Licensee Armelle Gby. LPA/licensee reviewed PIN 22-07, 22-09, 22-13, 22-15, 22-16 and 22-18. There are 4 clients at the facility. PIN sign up: ccldpolicynotification@dss.ca.gov Licensee agreed to submit Infection Control Plan (LIC 9282) by June 30, 2022.

LPA arrived at the facility and was screened by Licensee. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. At approximate 1:30pm LPA learned through interviews with Licensee that individual (I1) had been working providing care and supervision to clients in care for one day. Per Licensee, I1 has not been associated to the facility yet, LPA informed Licensee that individual (I1) is fingerprint, but they are not associated to the facility and should never be working and providing care to clients prior to a criminal record clearance or exemption. Required posters were observed including (Resident's rights, Emergency plan/numbers, CCLD complaint poster, and visitor policy).

LPA/Licensee toured the facility, it was found to be clean, good repair and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 11/2021 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational. Hot water temperature measured 127.4 and 130.6 degrees F which is not within Title 22 acceptable regulation of 105 to 120 degrees F in 2 out of 2 client’s bathrooms while touring facility on 6/21/22 at 3:00PM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Facility records reviewed, staff have CPR, 1st Aid certifications and vaccination records which includes 100% vaccination rate for clients and staff. LPA reviewed 4 out of 4 client files and observed current medical assessments, admission agreements, need/services plans and appraisals. P&I's are kept locked and are not co-mingled.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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Document Has Been Signed on 06/21/2022 04:06 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/21/2022 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HAVEN CARE HOME LLC
FACILITY NUMBER: 486804040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e)All individuals... shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Dpt...This requirement is not met as evidenced by:
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Licensee removed individual (I1) from the facility until I1 has a clearance as required by law. Licensee will associate individual and will submit a LIC9098 self-certification that I1 was removed from facility to CCL by POC due date.
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Based on LPA observation, record review and interview with Licensee did not ensure to obtain a criminal record clearance for individual (I1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assesed for the amount of $100 per day.
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Type A
06/22/2022
Section Cited
CCR80088(e)(1)

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80088(e)(1)Furniture, Fixtures..- (e)(1) Hot water temperature controls shall be maintained to... attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F. **This requirement was not met as evidenced by:
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Facility agrees to check on hotwater temperature to ensure that it stays in compliance w/ Title 22 Regulations. Facility to submit CCLD with a LIC9098 self-certification that hotwater is within range per regulation by POC due date and will submit after 7 days of hot water temperature log for clients' bathroom faucets.
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Based on observation during today's visit water tested in 2 of 2 bathrooms read at 127.4 and 130.6 degrees F this is an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


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: 06/21/2022
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Continued from LIC809...

Toxins, cleaning solutions, and other hazardous items are stored in a cabinet under the sink inaccessible for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All two client’s bedrooms have lighting and appropriate furnishings. In addition, LPA advised facility to ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility clients. Administrator Armelle Gby Certificate # 6057032735 expires on 8/26/2022.

During today's visit LPA followed up on a SOC341 filed by the facility regarding possible financial abuse to Client (C1). Per SOC341 report, Licensee noticed suspicious interactions between C1 and a person that C1 said met on Instagram since the beginning of May 2022, C1 had been having telephone conversations with a person named Ariana to whom C1 has been sending money in the form of gift cards. About two weeks ago, C1 asked facility staff for their social security number to forward to such individual which raised flags of concern of potential identity theft. Also staff overheard conversations while C1 was in a common area that they pressured to send money as soon as they get paid. Day Program where C1 attends has reached out to Licensee notifying that C1 has been sending money to a person in Mexico that was met on social media. Licensee notified their Service Coordinator at NBRC and Vallejo Police Department. Per Licensee, Service coordinator had a meeting with Licensee and will request guidance because C1 is not conserved. In the meantime, Licensee was instructed to don't provide their social security information to C1. During today's visit, LPA obtained C1's physician's report (LIC602) dated 1/25/22 were client has been diagnosed with an intellectual disability, ambulatory, needs help managing their own cash resources (P&I). Also, C1's Individual Program Plan dated 7/20/21 confirmed that C1 needs assistance managing their finances (P&I), C1 receives their funding for Board and Care through New Leaf, the NBRC vendor for representative payee services.
LPA will follow up with the police department and other involved agencies.

LPA obtained updates of the following documents: LIC 500- Personnel Report, LIC 308- Designation of Responsibility, LIC 402- Surety Bond, LIC 400- Affidavit Regarding Client Cash Resources
LIC 610- Emergency Disaster Plan. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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