PINE HAVEN LLC

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405(a)All facilities shall have a qualified and currently certified administrator… The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility… this requirement was not met as evidenced by: Based on observations and interviews, the Licensee did not comply with section 87405 when the facility did not appoint an administrator to be on the premises a sufficient number hours to manage facility operations, which is a potential health and safety risk to residents in care.

Official plan of correction

Plan of Correction Licensee agrees to appoint an administrator and submit required documents to the Fresno CCL office for review and approval by the POC due date.

Deadline recorded: Jul 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to S1 not having proper clearance before assisting residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Facility will have S1 removed and will not be allowed to return until proper clearance is completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to LPA observing R2 having full bed rails with no doctor orders, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Sandeep is working with family to get doctor's order for full bed rail. Verrification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above due to not having sufficient amount of food, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Facility will get more food items and verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due facility not having completed disaster drill log on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Sandeep will provide verification of drill log to the Dept by POC due date.

Official classification

Type B

Official code

87555(b)(15)

Regulation authority

CCR

What the official deficiency says

(15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to LPA observing open food in drawers and raw chicken not labeld or dated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Facility will have food labeled and stored properly. Inservice will be completed and verification will be sent to the Dept by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above the licensee did not comply with the section cited above due to R1 not having the correct admission agreement on file for the correct facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Sandeep stated R1 will be relocating per family request. Sandeep will provide a statement to the Dept by POC due date.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to facility not having verification of staff training for hospice residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Facility will reach out to hospice for training verification and provide verification to the Dept by POC due date.

Official classification

Type B

Official code

87506(b)(16)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to R1, R2, and R4 not having an personal property and valuables inventory on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Sandeep will have inventory list comepleted and verification will be sent to the Dept by POC due date.

Official classification

Type A

Official code

87307(e)(2)(A)

Regulation authority

CCR

What the official deficiency says

(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to R1 & R2's physician reports indicating they cannot have access to pools and the pool was not properly locked, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Sandeep will provide a picture of the third lock for the pool fence by POC due date.

Official classification

Type A

Official code

87629(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to R5 having injection medication, physician's report indicates they cannot administer their own injectable, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Facility will get an updated doctor's order regarding R5 can administer own injectable. Verification will be provided to the Dept by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to knives, lighter, and cleaning supplies being accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Sandeep will have items removed and placed in locked area. Verification will be sent to the Dept by POC due date.