At Haven Home

Type of visit: Case Management - Annual Continuation

On 08/29/2026, Licensing Program Analyst (LPA) M Vega arrived unannounced to conduct Required Annual Inspection. LPA was granted entry to facility. Administrator (AD) Jasmin Burns was notified and arrived a few minutes later. LPA conducted facility tour inside and out with Administrator. Residents observed at the facility after lunch time. The facility was observed to be at a comfortable temperature of 75 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 06/24/2026 Last fire drill recorded in 08/28/2026. Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered once a week. The census during the visit is three assisted living residents, three out of three residents on hospice. LPA toured resident bedrooms. Residents' rooms were toured and observed adequately furnished with bed, dresser, and adequate lighting. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication cart in the hallway. The first Aid Kit was observed with all required items. LPA toured the laundry room and observed chemicals were stored and locked in for staff use only. The facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. LPA reviewed facility Plan of Operation, Infection Control Plan, Emergency Disaster Plan and number of staff and residents’ files requested and reviewed during the inspection visit. Exit interview conducted, No deficiencies Cited during this visit. Report provided to administrator for facility records.the state’s words, verbatim · CDSS document, Aug 29, 2026

Type of visit: Required - 1 Year

On 08/05/2025, Licensing Program Analyst (LPA) V Gorban arrived unannounced to conduct Required Annual Inspection. LPA met with staff Esperanza Nishihama. Administrator (AD) Jasmin Burns was notified, and arrived shortly. LPA conducted facility tour inside and out of facility with staff. Residents observed at the facility after breakfast time. The facility was observed to be at a comfortable temperature of 75 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 05/01/2025 Last fire drill recorded in April 2025 Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered once a week. The facility is comprised of three The census during the visit is 6 assisted living residents, five out of six residents on hospice. LPA toured resident bedrooms. Residents' rooms were toured and observed adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 112 degrees F. LPA observed securely fastened grab bar and non-skid mat in shower area. Medications were stored in a locked medication cart in the hallway. The first Aid Kit was observed with all required items. LPA toured the laundry room and observed chemicals were stored and locked in for staff use only. The facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents. LPA reviewed facility Plan of Operation, Infection Control Plan, Emergency Disaster Plan and number of staff and residents’ files requested and reviewed during the inspection visit. Exit interview conducted, cited deficiencies attached on LIC9099 and discussed with administrator. Report provided to administrator for facility records.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Case Management - Incident

On 09/25/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct a case management inspection. LPA met with Administrator and announced the purpose of the inspection. During this visit LPA toured the facility inside and out to conduct residents safety check. The purpose of the visit was to follow-up on an incident which occurred on 9/18/2024. On 9/18/2024, Resident (R1) is a dementia resident, was found on the floor in her room. This incident was documented and reported to Regional Office, responsible party for R1 was notified. Due to violation of Title 22 regulation deficiency is cited on attached LIC809- D During this visit LPA requested facility files for review. Exit interview conducted, report signed and copy of this report with appeal rights provided to administrator for facility records. fathe state’s words, verbatim · CDSS document, Sep 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b) · Plan of correction due date: Sep 28, 2024

87705 Care of Persons with Dementia. (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia. This requirement was not observed as evidensed by: Based on interrviewes and record reviews facility staff failed to follow title 22 regulation resulted in dementia resident unassisted falling ans breaking her pelvis. Resident was taking the following day to the hospital were was diagnosed with broken pelvis, which poses health and safety risc to persons in carethe state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: The administrator will provide staff apropriate dementia training, completed physician report and a complete a preventative measure for resident safety and supervision for dementia residents to LPA by POC due date

Type of visit: Required - 1 Year

On 08/23/2024, Licensing Program Analyst (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA toured the facility with care giver Juliana Ruiz. Administrator Jasmin Burns, certification number 6050729740 and expiration date 02/03/2025 was notified of Licensing visit and was able to attend it. The facility was observed to be at a comfortable temperature, of 75 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. During the visit the facility residents were out at day program. Department phone number and infection prevention information signs were posted thought the facility. 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. A fire extinguisher was observed with service date of 04/18/2024. Private residents’ bedroom observed to be at comfortable temperatures. The bathroom’s water temperature was tested and recorded reading of 109 degrees F. Medications records storage observed to be locked in a cabinet in a hallway. Cleaning supplies were observed to be in a locked cabinet in the storage it the laundry room. An outdoor seating area was observed operational for residents in care. LPA reviewed staff and residents’ files. No deficiencies were observed and cited during this visit. Exit interview conducted. A report was signed, and a copy of this report was provided for facility records.the state’s words, verbatim · CDSS document, Aug 23, 2024