HAVEN'S HOUSE OF ASSISTED LIVING

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities: (a)(3) To be free from punishment,humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’... This requirement was not met as evidenced by: Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure resident’s rights and protection from abuse. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee agrees to complete a self-certification on physical abuse, financial abuse, and resident rights. The Licensee will submit proof of completion of the self-certification to Community Care Licensing by the Plan of Correction (POC) due date of 07/28/2026.

Deadline recorded: Jul 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and the Licensee's documented practices, the Licensee failed to perform the duties and responsibilities of the facility administrator as required by Title 22, Which poses immediate risk to the health, safety, and personal rights of persons in care.

Official plan of correction

The Licensee agrees to complete a self-certification on administrator qualifications and duties. The Licensee will submit proof of completion of the self-certification to Community Care Licensing by the Plan of Correction (POC) due date of 07/28/2026.

Deadline recorded: Jul 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's ... care needs as identified... This requirement is not met as evidenced by: Based on LPAs observation and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a immdadiate health and safety risk to residents in care.

Official plan of correction

Licensee has hired at least two additional staff. Licensee agrees to provide proof of training and an LIC 500 showing sufficient staffing to ensure staffing is adequate to meet residents needs during the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

Deadline recorded: Jul 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87654(g)

Regulation authority

CCR

What the official deficiency says

87465(g) Incidental Medical and Dental Care Services - 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident’s health, including an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on LPA observation, interviews and record review it was determined that staff failed to seek medical attention in a timely manner for R3 which poses a potential risk to the health, safety, and personal rights to residents in care.

Official plan of correction

Licensee agrees to hold an in-service training with all staff regarding policy and procedures for seeking medical attention in a timely manner as incidents and/or observations arise. Proof of training to be provided to CCL during the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

Deadline recorded: Jul 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident care needs. This requirement is not met as evidenced by: Based on records reviewed, interviews conducted, Licensee did not ensure sufficient staff were present to meet resident needs. This poses an immediate Health and Safety risk to residents.

Official plan of correction

Licensee agrees to ensure facility has sufficient staff to meet the needs of residents in care. Licensee to submit updated LIC500 to show care giving staffing levels needs the residents. LIC500 to be brought in for the in-person meeting at the Santa Rosa Regional Office on Monday, July 27, 2026.

Deadline recorded: Jul 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement is not met as evidenced by: Based on interview and observation with Licensee, they have conducted physical redirection of at least one resident, This poses an immediate Personal Rights risk to residents.

Official plan of correction

The licensee agreed to submit a self-certified declaration stating that all resident personal rights regulations have been reviewed with facility staff. Licensee shall submit the declaration as proof of correction to Community Care Licensing (CCL) by the Plan of Correction (POC) due date 07/25/2026.The licensee also agreed to ensure that all residents' personal rights are protected.

Deadline recorded: Jul 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated... To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement is not met as evidenced by: Based on interviews, record review, and observations, LPA determined that the Licensee failed to provide meals at scheduled times and failed to meet the residents' dietary needs. This poses an immediate Personal Rights risk to residents.

Official plan of correction

Licensee to ensure that meals are served at appropriate times and in a timely manner as per regulations. Licensee to submit a food service menu showing facility schedule of meal times and meals served. Submit POC by due date of 07/25/2026.

Deadline recorded: Jul 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia:(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure staff were aware when resident left the building without assistance. This poses an immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to ensure elopement plan; and address frequency of awol drills for staff. In addition, to conduct staff training regarding elopment and wandering behaviors. Proof of training with participants signature to be submittet Community Care Licensing by plan of correction due date 06/05/2026

Deadline recorded: Jun 5, 2026. A deadline is not proof that correction was completed.

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, and record review, the licensee did not comply with the section cited above facility Unable to provide proof of disaster drills being conducted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Licensee agrees to conduct disaster drill and submit proof of correction to Community Care Licensing by due date 03/20/2026

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a)Each licensee shall furnish ..., the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (B)Any serious injury as determined ... . This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above, Licensee failed to submit special incident report to the CCL as required which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure all resident incidents are reported to CCL as required. Licensee will complete training from an outside vendor on reporting requirements for whole staff and submit a plan for ongoing compliance by 10/21/2025.

Deadline recorded: Oct 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents... (a) In addition to the rights listed in ...: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict... This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined Facility refused to accept the resident (R1) back from the hospital. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to read regulation 87468.2 and submit written declaration acknowledging the understanding of regulation and the facility policies and procedures. Items to be submitted by date 10/21/2025.

Deadline recorded: Oct 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental (h) The following requirements...:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above. LPAs observed multiple instances of resident medication being pre-poured over 24 hours in advance. This is a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to conduct all staff training in medication administration to submit CCL with centrally store medication log for all residents in care by plan of correction date (POC) 08/18/2025.

Deadline recorded: Aug 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible a record of centrally stored prescription medications for each resident...: This requirement was not met as evidenced by: Based on observations made, Licensee didnot comply with the section cited above and did not ensure that there was a completed LIC622 or similar document with the all of the regulatory information required. This is a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to conduct all staff training in medication administration to submit CCL with centrally store medication log for all residents in care by plan of correction date (POC) 08/18/2025.

Deadline recorded: Aug 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, interview and observation the licensee did not comply with the section cited above in [1} out of [4} staff which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction 1)Licensee to submit in writting to CCL that employee S1 will not work by 03/11/2025 2)Licensee to submit proof of S1 being associated to the facility on the Guardian website by 03/14/2025

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 5 files did not have care plans or signatures for meetings which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction Copies of care plans to be submitted by the POC date of 3/27/24.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above in items were found unsecured in kitchen, laundry room, bathroom and resident room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2024 Plan of Correction Items were secured while LPA present. Licensee will designate areas to be locked and submit photos of locks and lock boxes by the POC date of 3/20/24

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidence by:** Based on record review and interview with Licensee, the facility did not comply with the section cited above in 1 out of 1 individuals (I1) without proof of background clearance or association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agrees to submitt in writing; a plan to ensure I1 is considered a resident and provide all documents required per regulation (admission agreement, 602, needs/service etc) by POC date 10/20/2023. In addition, Licensee completed an updated LIC200 for increase in capacity and provided to CCLD.

Deadline recorded: Oct 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87459(a)(4)

Regulation authority

CCR

What the official deficiency says

87459(a): The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to: (4) Transferring, including the need for assistance in moving in and out of a bed or chair. This requirement was not met as evidenced by: Based on interviews that were conducted, resident was bedridden which requires a higher level of care for the resident that was in placement. Facility is licensed to retain 4 residents that are Non-Ambulatory which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.

Official plan of correction

Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.

Deadline recorded: Apr 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202(a): All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons This requirement was not met as evidenced by: Based on a review of the STD 850 and an interview with an outside provider, facility retained a resident that was bedridden. Facility is currently Fire Clearance approved for 4 Non-Ambulatory residents which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.

Official plan of correction

Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.

Deadline recorded: Apr 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506(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 was not met as evidenced by: During the investigation, facility did not retain resident records which included the Medication Assessment Record (MAR) that documents medication administration. This is a potential health, safety and personal rights risk to the resident(s) in care.

Official plan of correction

Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.

Deadline recorded: Apr 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by: During the opening of the complaint on March 14, 2023 at approximately 01:00 PM, LPA was greeted at the door by a Staff Member who was not background clearand associated to the facility

Official plan of correction

Licensee shall ensure that ALL staff members are fingerprint cleared and associated to the facility prior to working at the facility. In addition, LPA shall provide a written summary on how future compliance will be met. POC due date on March 15, 2023.

Deadline recorded: Mar 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1)-Personal Rights of Residents in All Facilities: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA observed during the facility tour on September 13, 2022 that a baby monitor was inside the residents room, and was being used to monitor the resident's call for assistance.

Official plan of correction

Plan of Correction shall include the removal of the baby monitor.

Deadline recorded: Oct 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(11): Personal Rights of Residents in All Facilities : To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: The auditory baby monitor was turned on. The receptor is kept in the live-in kitchen area, which can be heard by other facility staff, residents and visitors. This violation presents a potential Personal Rights violation.

Official plan of correction

Plan of Correction shall include the removal of the baby monitor.

Deadline recorded: Oct 6, 2022. A deadline is not proof that correction was completed.