At Haven Home II

Type of visit: Required - 1 Year

On 01/27/2026, Licensing Program Analyst (LPA) M Vega conducted a required unannounced Annual Inspection visit. LPA introduced self, stated purpose of visit, and allowed entrance by House Manager - Myra Torres. Administrator Jasmin Burns was contacted and was not able to attend Annual Inspection. LPA observed the facility to be clutter free, exits to be free from obstruction, and odor free. LPA observed all residents in their rooms. Carbon monoxide detector was tested and in working condition. Facility bacteriological analysis completed within year, analysis up to date. LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Fire extinguisher was observed with a service date of 12/24/2025. All Clients’ bedrooms were observed with comfortable temperatures. Facility temperature read at 71 Degrees F. Medications are stored in a locked cart the office, LPA observed cleaning supplies, knives and sharp objects are secured and inaccessible to residents in care. Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2-day supply of fresh perishables to be properly stored. An emergency disaster supply was observed. LPA reviewed a sample of employee records which were complete at the time of inspection. All staff members are properly associated with the facility. LPA reviewed resident files which were current and up to date. Continuation on LIC 809C 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 LIC 309 Administrative Organization 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: 02/10/2026 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. No deficiencies issued during this inspection. An exit interview was conducted with the House Manager - Myra Torres A copy of this report was given to HM whose signature on this form confirms receipt of these reports.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Due to neglect, resident sustained a pressure injury Staff retained resident with a prohibited health condition

On 04/12/25, Licensing Program Analysts (LPAs) L. Salazar and M. Vega arrived to the facility unannounced to do deliver findings on the above allegations. LPAs were greeted by house manager, Myra stated the purpose of the visit and were allowed entry. Staff contacted Administrator vis telephone. LPAs met with House manager Myra Torres to discuss the findings of the complaint allegations. During the investigation, LPA Salazar conducted interviews and records review. Records review show Resident R1 had a blister on their heel in September of 2024 and Home Health was ordered. Compassion Home Care Home Health records obtained for the period of 11/08/24 through 01/06/2025 states R1 to have an unstageable presssure injury on their heel and R1 should be transferred to Skilled Nursing for care. Interviews with Administrator and facility staff state facility was not observing or caring for the wound since they were not skilled professional. Based on the information received, the preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D. An immediate civil penalty is being assessed in the amount of $500 for observation of resident resulting in a prohibited condition. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care. An exit interview was conducted with Administrator Jasmin Burns via telephone and house manager Myra Torres. A copy of this report and appeal rights were discussed and will be emailed by next business day. A plan of correction was developed by Administrator and reviewed with LPA at the time of visit. Substantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2025 · control 24-AS-20241204100214

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 14, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as...a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by LPAs observation of records review of incident report dated 09/20/24 stating the heel wound was a small blister and Home Health records dated 11/07/24 stating R1's wound is an unstageable pressure ulcer. Interviews with staff state they did not observe or care for R1's heel wound because they are not nurses and home health services are being received. An immediate civil penalty in the amount of $500 is hereby assessed. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.the state’s words, verbatim · CDSS document, Apr 12, 2025

Plan of correction: Administrator will review Home Health plan of care prior to resident's receiving home health services. Administator will provide a statement stating they have read and understood the regulation being cited.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a) · Plan of correction due date: Apr 14, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:LPAs observation of Home health records dated 11/07/24 stating the heel wound is an unstageable pressure ulcer and an exception to retain a prohibited condition was not submitted. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.the state’s words, verbatim · CDSS document, Apr 12, 2025

Plan of correction: Resident R1 was relocated to skilled nursing. ** POC Cleared**

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) M Vega and L Salazar conducted an unannounced Case Management Annual Continuation visit at approximately 10 am and was greeted by Staff, House Manager - Myra Torres. Upon arrival, LPAs observed some residents in the common area watching television. All staff at facility today were found fingerprint cleared and associated to the facility. On today's unannounced inspection, LPA M Vega observed the common rooms to be free from obstruction and clear well-lit pathways. Kitchen clean free of unsecured medications, sharps and cleaning toxins. The kitchen has been updated since the last visit, cabinets have been painted. Retested Water temperature at 3 points in the facility. Room 3 tested 105.6 Degrees F, Room 5 tested at 117.1 degrees F, Room 9 tested at 120.9 Degrees F. Cabinets and areas of concern addressed in original report were cleaned and clear of dust and exterior did not have any obstructions. Uneven pavement has been fixed. Two (2) resident files were reviewed and observed complete with Admission Agreements, Physician Reports, Needs and Services Plans/IPP current. Two (2) Staff 1 (S1) and Staff 2 (S2) files were reviewed. Staff 1 found complete with employment applications, fingerprint clearances, Health checks and CRP/First Aid certifications current to January 19, 202, training missing for S2. Exit interview was conducted and a copy of this report LIC809, Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of the residents in care. Continuation on LIC 809 C An exit interview was conducted with House Manager. A copy of this report and appeal rights were discussed and provided at the time of visit. Obtained permission from administrator for House manager Myra to sign forms.the state’s words, verbatim · CDSS document, Apr 12, 2025

The state marks this report as 26 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 01/29/2025, Licensing Program Analysts (LPAs) M Vega and L Salazar conducted a required unannounced Annual Inspection visit. LPAs introduced self, stated purpose of visit, and allowed entrance by staff. Administrator Jasmin Burns was contacted however was not able to attend. Spoke with House Manager – Myra Torres. LPAs observed interior of the facility to be clutter free, exits to be free from obstruction, and odor free. LPA observed 3 residents sitting at the living room and a few others in their rooms. LPAs toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms. Facility was observed to have dust build up in vents and walls. All fire exit routes were free and clear of obstructions. Exterior walkways were observed to have a hose across the walkway obstructing the path. Uneven pavement was also observed which could present a tripping hazard to residents. Carbon monoxide detector was tested and in working condition. Water temperature was checked in bathrooms 5 and read at 96-degree Fahrenheit, kitchen sink read at 104.9-degree Fahrenheit and bedroom 9 sink read at 131.2 degree Fahrenheit. Continuation on LIC 809C LPAs reviewed a sample of employee records which were missing current training verification. LPA reviewed resident files which were not current or up to date. Resident records are were observed to be the wrong physicians report form (LIC 602), not the RCFE physician report (LIC602a), however, house manager is scheduling appointments this week to obtain the correct forms. Files also have missing documents and files that are not up to date, Medications are stored in a locked cart the office. Exit interview was conducted and a copy of this report LIC809, Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. An immediate Civil Penalty in the amount of $500 is being assessed for fire clearance violation. 3 out of 11 residents were observed to not be able to turn without assistance. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of the residents in care. An exit interview was conducted with House Manager. A copy of this report and appeal rights were discussed and provided at the time of visit. Obtained permission from administrator for House manager Myra to sign forms.the state’s words, verbatim · CDSS document, Jan 29, 2025

The state marks this report as 26 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 12/5/24 Licensing Program Analysts (LPAs) M. Garza and L. Salazar arrived at facility for an unannounced case management. LPAs met with Direct Care Staff, Teny Daraphet, explained reason for visit and was permitted entry into the facility. Administrator, Jasmin Burns and House Manager, Myra Torres arrived a short time later. This case management visit is being conducted due to observations made during an initial complaint visit on 12/05/2024. The following issues were observed during visit: Room 10 observed with hole behind door in need of replacement Clutter in garage in need of removal Refrigerator in garage in need of cleaning/repair Food source is not the required 2-day perishable/7-day non-perishable Food source in kitchen cupboard observed to be expired Screws observed near top of cupboard storing food appearing to be secured Medications/items observed unlocked/accessible in kitchen cupboard, kitchen refrigerator, in R6 closet and hallway cupboard Hood vent observed open and in need of repair under kitchen cupboard Bottom kitchen cupboard door broken and in need of repair/replacement Food not properly stored/dated in refrigerator Bedframe for R9/room 9 observed on floor R11 observed with scissor on TV tray unsecured and accessible to residents in care R1's window observed locked with board preventing from opening R1's exit door observed with a lock at the top and blocked with chair preventing from exiting Front door observed broken and not properly latching Front door observed with lock at bottom of door PUB 475 observed inappropriately sized (8x10 and not 20 x 26) Deficiencies and TV's provided per Title 22. Exit interview completed with Licensee, Jasmin and House Manager, Myra. A copy of this report, deficiencies, TV's and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 20, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observation of Room 10 observed with hole behind door in need of repair. Clutter in garage in need of removal. Refrigerator in garage in need of cleaning/repair. Hood vent observed open and in need of repair under kitchen cupboard. Bottom kitchen cupboard door broken and in need of repair/replacement. Front door observed broken and not properly latching. This poses a potential health safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee stated they will make repairs to the items listed. Licensee stated they will provide pictures to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Dec 20, 2024

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: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not met as evidence by LPA observation of R1's window observed locked with board preventing from opening R1's exit door observed blocked with chair preventing from exiting. Front door observed with lock at bottom of door.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee will have a meeting with family and staff regarding regulation. In-service sign in sheet and training material will be sent to CCL by POC date. Chair and locks will be removed. Pictures will be provided to CCL as proof of correction by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 6, 2024

87465 Incidental Medical and Dental Care...(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: LPA observation of medications observed unlocked/accessible in kitchen cupboard, kitchen refrigerator, in R6 closet and hallway cupboard. This poses an immediate health, safety and or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Licensee stated they will provide a plan of correction in writing by POC date. In-service training will be completed with all staff. In- service sign in sheet and training material will be submitted as proof of correction within 7 days to CCL..

Type of visit: Case Management - Incident

On 12/05/24, Licensing Program Analysts (LPAs) L. Salazar and M. Garza arrived to the facility unannounced to conduct the required Health & Safety inspection. LPAs were greeted by caregiver Kenny, stated the purpose of the visit, and were allowed entry into the facility. Licensee/Administrator was called and arrived to the facility shortly after LPAs arrival. LPA Salazar discussed the details of the visit with House Manager (HM). LPA requested additional information regarding 2 incident reports that were submitted for Resident R1. LPA reviewed R1's file and obtained LIC602A and hospital discharge summary. X-ray report dated 09/27/24 stated R1 had a right hip fracture, not a femur fracture, as stated in the incident report. LPA did not observe a Pre-Admission Appraisal (LIC603A) or Needs and Service appraisal in R1's file. R1's admission was 09/17/24. LPA will conduct interviews and return at a later date if additional information is provided. Based on LPA’s records review and interviews and in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D. If not corrected this poses an immediate risk to residents in care. An exit interview was conducted with Licensee/Administrator. A copy of this report and appeal rights were discussed and provided at the time of visit. A plan of correction was developed by Licensee/Administrator and reviewed with LPA with a POC date of 12/06/24.the state’s words, verbatim · CDSS document, Dec 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87457(c)(1) · Plan of correction due date: Dec 6, 2024

87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement was not met as evidenced by LPAs observation of resident's file. No pre appraisal or needs and service plan was obtained at the time of admission and not observed in file.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: Administrator will provide documentation verify they have read & understand the regulation requirements for admissions by POC date.

Type of visit: Required - 1 Year

On 2/20/24, Licensing Program Analyst (LPA) B. Miranda conducted a required unannounced Annual Inspection visit. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator Jasmin Burns was contacted and arrived shortly after. LPA observed the facility to be clutter free, exits to be free from obstruction, and odor free. LPA observed 4 residents sitting at the kitchen table and 2 residents sitting in the living room area. LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Majority of medications are stored in a locked cart the office, LPA did observe some medication unlocked and accessible to residents. Majority of toxins, cleaning supplies, knives and sharp objects are secured, LPA did observe some degrease solution to be unlocked and accessible to residents. In an unlocked drawer LPA observed a hammer and screw driver. Carbon monoxide detector was tested and in working condition. Water temperature was checked in various facets and read at 96.7 degree Fahrenheit. LPA observed various toilets to have a mildew/mold ring and one resident's shower to have mold. LPA reviewed a sample of employee records which were missing current training verification. Three staff members are not properly associated with the facility. LPA reviewed resident files which were not current or up to date. S1 is missing current physician report and PRN on file. Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator.the state’s words, verbatim · CDSS document, Feb 20, 2024