A Heavenly Haven, Inc. II

Type of visit: Required - 1 Year

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Staff #1, who granted access to the facility. Administrator arrived shortly after, and LPA explained the reason for the visit. At 10:10am LPA conducted a physical plant tour and observed the following: Facility is licensed for capacity of six (6) Non-Ambulatory of which one (1) may be Bedridden. Hospice waiver for four (4) residents is also approved. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. Medications were kept in the kitchen cabinet and observed to be locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. The fire extinguisher is located in the kitchen area and was last serviced on 02/18/2025. Laundry is located by the kitchen, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. The washer/dryer appear to be in a good condition. Facility maintains a temperature of 77°F. The facility has six (6) private resident bedrooms (Rooms #1, 2, 3, 4, 6 & 7) and one room #5 for live-in staff. Resident rooms #1 #3 and #4 have direct exits to the outside. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 111.4°F. There is one bathroom in the hallway between room #3 and #4. Bedrooms #4 and #7 have its own bathroom. The shared bathroom and the bathroom in room #7 have a shower with non-skid mat. Continue on LIC809-C The bathroom in room #4 has a tub with a non-skid mat. All bathrooms have grab bars. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:00am they were tested and observed to be operational. The exterior passageways were clean and clear of any obstructions. LPA observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. There are no bodies of water on the premises at the present time. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. Between 11:30am to 12:30am, LPA reviewed records of five (5) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentation. LPA collected Certificate of Liability Insurance and LIC500. Administrator certificate is valid until December 2025. No deficiency cited during today's visit. Exit interview conducted and a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 29, 2025

Type of visit: Required - 1 Year

At 12:30pm, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit. At 12:35pm LPA conducted a tour of the physical plant and observed the following: Facility has six (6) bedrooms designated for resident’s use, four (4) bathrooms and one staff room (room #2). Facility is licensed for capacity of six (6) of which three (3) non-ambulatory and one (1) bedridden resident. It has also been approved for a hospice waiver for four (4) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. Facility maintains a temperature of 76°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher was observed in the kitchen and the living room area and was last serviced on 02/02/24. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 112.6°F. Extra towels and linens were readily available. Laundry area is also located by the kitchen area and LPA observed all chemicals and detergents are kept locked and inaccessible to residents. At 1:10pm, smoke detectors and carbon monoxide monitors were tested and observed to be functional. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 1:15pm to 2:00pm, LPA reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.the state’s words, verbatim · CDSS document, Jun 20, 2024

Allegation investigated: Staff inappropriately touch residents

Licensing Program Analyst (LPA) Angela Panushkina, conducted a subsequent visit to deliver final finding. LPA met with the Administrator and LPA explained the reason for the visit. At 10:00 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations During the initial visit made on 07/07/23, LPA Ruiz met with the Administrator and requested client and staff roster. LPA also requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, etc. Between 11:00 AM – 12:15 PM, LPA conducted an interview with the Administrator, two (2) out of four (4) and one (1) out of six (6) residents, who were able to communicate. Continue on LIC9099-C Unsubstantiated Allegation: Staff inappropriately touch residents It was reported that facility "Staff inappropriately touch residents". To investigate this allegation, during the initial visit conducted by LPA Ruiz on 07/07/23, LPA interviewed the Administrator and two (2) staff involved in R1's care and supervision and all denied the allegation and reported no resident ever complained staff touched/handled them inappropriately and also they never seen any staff inappropriately touched R1 and or other residents. During today's visit, Administrator reported that all facility staff received training on how to handle residents and that all residents are being treated with care and respect. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted, copy of report signed and deliveredthe state’s words, verbatim · CDSS document, Nov 7, 2023 · control 31-AS-20230706094717

Type of visit: Required - 1 Year

At 10:20am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit. At 10:25am LPA conducted a tour of the physical plant and observed the following: Facility is a Residential Care Facility for the Elderly which was licensed for capacity of six (6) of which three (3) non-ambulatory and one (1) bedridden residents. Facility has six (6) bedrooms designated for residents use, four (4) bathrooms and one staff room. Facility has been approved for a hospice waiver for four (4) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. . Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 74°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 119.1°F. Extra towels and linens were readily available. The fire extinguisher was observed in the living room area and was last serviced on 03/27/2023. Laundry area is also located by the kitchen area and LPA observed all chemicals and detergents are kept locked and inaccessible to residents. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 11:00am to 12:00pm, LPA reviewed records of three (3) residents and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.the state’s words, verbatim · CDSS document, Nov 7, 2023