486804196-7-31-2025-21-AS-SSTN-DK4Q9T-20250731115851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804196
Report Date: 07/31/2025
Date Signed: 07/31/2025 11:59:10 AM

Document Has Been Signed on 07/31/2025 11:59 AM - 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:	HOLY HAVEN II		FACILITY NUMBER:	486804196
ADMINISTRATOR/ DIRECTOR:	ENRIQUEZ, LESLIE ANN P		FACILITY TYPE:	740
ADDRESS:	265 HOLLY DR		TELEPHONE:	(408) 724-3120
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 5		CENSUS: 0	DATE:	07/31/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Licensee/Administrator-Leslie Enriquez		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:35 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-year inspection and was greeted by Licensee Leslie Ann Enriquez. The facility was recently vendorized with North Bay Regional Center (NBRC) in June of 2025 and currently the facility has no residents in care. Licensee indicates that NBRC plans to only send them 4 residents and they may look to convert one or two bedrooms to staff room on their facility sketch. Currently fire clearance has been approved for five (5) non-ambulatory residents. Facility has a waiver for three (3) residents receiving hospice services. Facility now has a dementia plan on file with Community Care Licensing (CCL). At approximately 9:50 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home with auditory signals activated on all exits, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured at approximately 108 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed 4 of 4 bathrooms had required anti-slip mats and grab bars. LPA observed a supply of incontinent care products and paper products available to residents. LPA observed adequate supply of towels, bedding sheets, and hygiene products. Hallways are equipped with night lights and residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. There is a sufficient amount of dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets as well as under the kitchen sink. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable foods, and at least one week of non-perishable foods or emergency water. LPA observed a sample menu posted in the common area to indicate a healthy and balanced set of meals for residents in care. Continued on LIC809-C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: HOLY HAVEN II	FACILITY NUMBER: 486804196
	VISIT DATE: 07/31/2025

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continued from LIC809...
The facility has both internet service and operating phone and a new phone number that will be updated for the facility. Facility has a designated area with locked cabinets for centrally stored medications and resident, staff, and facility files. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and games available for resident use. LPA obtained a newly developed sample activity schedule for residents.
Facility has one fire extinguisher, which was observed to be fully charged and last inspected on 03/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Licensee has posted hard copies of the required emergency disaster plan and maps, admissions agreement, theft and loss program, personal rights information, and reporting posters in facility communal areas. The facility Emergency and Disaster Plan for Residential Care Faculties for the Elderly (LIC610E) was updated during inspection on 07/31/2025 including new facility phone number. LPA informed Licensee that visiting hours shall be posted as well one residents are in care. Licensee is aware of the association and staff transfer process.The backyard features paved walkways and a patio with shaded seating for resident outdoor use. In addition property has a number of overgrown fruit trees with dropping fruit and bushes that could present a potential slip/trip hazard, as well as, increased fire risk and licensee was advised to aggressively cut-back trees and bushes and remove fallen fruit on the ground and maintain the patio free from tripping hazards.

At approximately 10:50 AM two(2) of 2 staff files were reviewed and one (1) of (2) not have evidence of required 40 hours of initial/required training, however no residents are in care and licensee was given information on educational requirements for those that administer medicines and general caregivers at an RCFE, including the need for 20 hours of annual documented training with emphasis on dementia, postural supports and prohibited conditions.

LPA obtained updated copies of LIC610E, Liability Insurance (valid until 04/2026), and activity schudule.

Licensee is ask to submit both a new LIC500 and LIC9020 ONCE they receive their first resident in care.

No deficiencies are cited today. Technical Advisories are issued from the California Code of Regulations (CCRs), and/or the Health and Safety Code.

This report was reviewed with Licensee.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

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