At Haven Home

Type of visit: POC

On 7/31/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Plan of Correction(POC) inspection. LPA contacted Administrator Jasmine Burns and announced the purpose of the inspection. This visit was conducted as a follow-up to a Required Annual Inspection which was conducted on 7/20/2023. During the visit, LPA toured the facility and verified that corrections were made to deficiencies which were observed and cited on 7/20/2023. No deficiencies were cited during the inspection. A copy of the report was provided to the administrator and exit interview conducted.the state’s words, verbatim · CDSS document, Jul 31, 2023

Type of visit: Required - 1 Year

On 7/6/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Manager Maria Knight and announced the purpose of the inspection. LPA toured the facility inside and outside. Smoke-detectors and carbon-monoxide detectors were present and operational. Facility was clean and odor free. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Sharp items were secured in a locked drawer. A locked cabinet was observed to store resident medications. LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed a sample of resident files. The following deficiencies were observed during the inspection: three exterior doors were locked due to dementia residents being a risk to exit the facility, one out of five resident files did not include an admission agreement, one out of five resident files did not include a physician's report, staff were utilizing full length bed rails for a resident who was not on hospice care, and staff were not documenting doses of a PRN on one out of five residents' medication administration records(MAR's). See attached LIC 809D's for five type B citations issued in accordance with Title 22, California Code of Regulations. CCLD requested the following documents to update the facility file: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, LIC 9020 Regirtser of Facility Residents, and a copy of current Administrator’s Certificate. Exit interview conducted. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 20, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) L. Cabrera conducted a subsequent Case Management visit regarding complaint # 24-AS-20220726110502, previously closed by LPA with a finding of Substantiated. Admission Agreement was not signed by the licensee or the licensee’s designated representative and does not indicate rate for basic services. Facility had improper Agreement. LPA met with Administrator Jasmin Burns and Manager Maria Knight. LPA provided a copy of this report to the Administrator and the Appeal Rights.the state’s words, verbatim · CDSS document, Nov 7, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: Nov 11, 2022

87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document... if any, and the licensee or the licensee’s designated representative no later than seven days following admission... This requirement is not met as evidenced by: During the complaint investigation complaint, it was reported Licensee/Administrator did not provide Admission Agreement to Resident’s (R1) Responsible Party upon signing the admission agreement and Admission agreement was not signed by the licensee, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: Licensee will submit written statement of plan of how a copy of the admission agreement will be provided immediately to residents and resident's responsible party upon signing and Administrator will make sure admission agreement is filled out completely, to CCL by POC due 11/11/2022.

Allegation investigated: Staff will not accept resident back at facility

Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility. LPA met with Administrator Jasmin Burns and Maria Knight, Manager . LPA went over the allegation and the finding with the Administrator. During the course of this complaint investigation LPA interviewed staff, obtained and reviewed facility records. It was determined based on the interviews and records reviewed that the above allegation is SUBSTANTIATED. Based on LPA interviews and reviewed records, LPA found that Administrator Jasmin Burns did not issue an eviction notice and did not follow the 87224 Eviction Procedures to legally evict Resident (R1). Per interviews, it was reported facility did not accept R1 once resident was cleared and discharged from the hospital. Per Admissions Agreement signed and dated on 12/20/2021, R1 has been living at the facility since 12/20/2021. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.Exit interview was conducted. LPA provided the facility with a copy of this report and Appeal Rights. Substantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2022 · control 24-AS-20220726110502

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Aug 3, 2022

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: Based on observation, record review and interview, the Licensee did not serve the resident with a proper 30-day eviction notice, which poses a Potential Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: Administrator shall review Title 22, Division 6, Chapter 8, Section 87224: Evictions Procedures. Administrator shall provide in writing that the regulation has been read and understood by 08/08/2022. Administrator stated she will serve an eviction notice by 08/03/2022 to R1's responsible party.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Jasmin Burns and Manager Maria Knight. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathrooms and kitchen. Bedrooms were checked. The exterior tour was conducted. LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Resident’s files have updated emergency contact information. Exit interview was conducted. Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below: Residential Care Facility for the Elderly (RCFE): · LIC 308 Designation of Facility Responsibility · -as applicable: LIC 309 Administrative Organization · -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources · -as applicable: LIC 402 Surety Bond · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly · LIC 9020 Register of Facility Clients/Residents · Copy of current Liability Insurance · Copy of current Administrator Certificate · Alternate contact information including name, telephone number, & email address. Please submit the above forms/information to Fresno CCL by: 08/09/2022. As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.the state’s words, verbatim · CDSS document, Aug 2, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident's dental wear is missing.

Licensing Program Analyst (LPA) Lady Cabrera conducted the complaint investigation visit to the facility. Administrator Jasmin Burns was unavailable in person and designated Maria Knight to sign the report. Based on interviews and records, it was determined that the above allegation Resident's dental wear is missing is UNFOUNDED. Per records review, Resident (R1) needs assistance with personal care and has been diagnosis with dementia. Staff (S1) was assisting R1 with brushing her teeth. S1 observed R1's partial dentures were missing. R1 was unable to remember how it happened. S1 did not observe any type of injuries on R1. Facility staff found R1’s partial dentures and placed them in a safe location. Facility notified R1’s Power of Attorney. This agency has investigated the complaint alleging (Resident's dental wear is missing). We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Oct 19, 2021 · control 24-AS-20211014120039

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility to obtain more information. Administrator Jasmin Burns was unavailable in person and designated Maria Knight to sign the report. The visit is to respond an incident report that was submitted to CCL Office 09/07/2021 and the incident occurred on 09/06/2021 regarding Resident (R1) pinching R2. Facility staff responded immediately and redirected the residents. Administrator reported R2 had a small red mark on her right arm and skin was intact. Facility will continue to monitor residents and provide redirection when needed. No follow-up required. Exit interview was conducted. Administrator was provided with a copy of this report.the state’s words, verbatim · CDSS document, Oct 19, 2021