Haven House of San Rafael

Type of visit: Required - 1 Year

At approximately 1:15 PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Administrator Henri Van Meines. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for six (6), with one (1) Hospice residents currently in care, and is approved for all non-ambulatory residents. At approximately 1:25 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 11/24. Smoke detectors are interconnected and carbon monoxide detector was tested and operational during inspection. Facility has recently installed a new water heater and is in the process of calibrating it, Licensee will keep a seven (7) water log and submit to LPA. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed one (1) locked shed unit and observed the contents to consist of resident care equipment and overflow storage. Facility has an internet access device and internet available to residents in care, and the phone was tested and operational during today's inspection. Continued LIC809C... Continued from LIC809... Facility conducts quarterly disaster drills, and the most recent drill was conducted 8/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 8/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. LPA observed a back up generator for emergency purposes. At approximately 1:55 PM LPA conducted a review of four (4) resident records. All required documentation present. At approximately 2:20 PM LPA conducted review of four (4) staff records. All required documentation present. At approximately 2:45 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Henri Van Meines Administrator Certificate 7020155740 expires 8/27. Updated copies of the following documents shall be submitted to CCL within 30 days of this visit: Liability Insurance LIC308 - Designation of Responsibility LIC400 - Affidavit Regarding Client Cash Resources LIC610E - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Nov 24, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived uannnounced to conduct a Case Management – Other visit and met with House Manager, Helen Hocog. Licensee, Harry Van Meines, was available by phone. The purpose of today’s visit is to amend documents related to Complaint 21-AS-20250729125340 that was created on 08/01/2025 and obtain new signatures. The following amendments were made to LIC9099D under Complaint 21-AS-20250729125340: Regulation 87608(a)(5)(B). The Type B citation issued on 08/01/2025 was amended to a Type A citation. Plan of Correction Due Date was amended from 08/15/2025 and changed to 08/02/2025 to reflect the Type A citation. Plan of Corrections verbiage was amended to include additional observations made during 08/01/2025 visit regarding R1’s gait belt. Regulation 87468.1(a)(1). The verbiage for Type B citation issued on 08/01/2025 was amended to add the word “written,” to identify type of consent. During visit conducted on 08/01/2025, LPA observed that the secondary bed rail on R1’s bed and gait belt were removed. The Type A citation issued today, on 08/13/2025, has been cleared with Plan of Corrections Letter provided during today’s visit. On 08/08/2025, Licensee submitted proof of physician order for half bed rail, staff training on postural supports, and proof of removed camera to the Department. Deficiencies cited on 08/01/2025 have been cleared with Plan of Corrections Letter provided during today’s visit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, Plan of Corrections, Plan of Corrections Letters, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 13, 2025

Allegation investigated: Facility staff are using bedrails to restrain resident Personal Rights

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a Complaint Investigation regarding the above allegations and met with House Manager, Helen Hocog. Licensee, Harry Van Meines, arrived during visit at approximately 12:00PM. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation of “Facility staff are using bedrails to restrain resident," and "Personal Rights." Complainant alleged the following: Resident 1 (R1) doesn't want to be put in bed at 7:30PM and wants to go to bed at 10:00PM. Facility put a camera and motion sensor in R1's room to monitor them, and facility staff have added a second railing to R1's bed to prevent them from getting out of bed. Photo provided to LPA showed a resident's bed with two half rails pulled up. The half rails were shown to be affixed at the top and lower halves of the bed with a small gap in the middle. During visit on 08/01/2025, Interview conducted with House Manager and Staff Member 1 (S1) revealed that they use the Continued on LIC9099C Substantiated Continued from LIC9099 second half bed rail and the gait belt as a safety precaution for R1. Per interviews, the gait belt is used as a safety precaution for R1 when staff are doing other tasks such as cooking or providing care to other residents. LPA was informed that the video camera has no audio and was placed as an additional safety precaution to notify Night Shift staff when R1 gets up at night. Interviews further revealed that R1's family was verbally notified of the camera/video monitoring. Interview conducted with R1 revealed that they preferred to go to bed at 10:00PM but usually get put into bed at 9PM. Per R1, they are unable to get out of bed on their own due to their recent injury and would require assistance to leave. LPA conducted a walkthrough of the facility and observed the following: R1's bed had two half bed rails creating a full bed rail (picture taken). LPA also observed that R1 had a white gait belt around their wheelchair. Review of R1's file showed that they are not receiving hospice services at this time and do not have a physician's order for use of bed rails or for use of a gait belt. There is also no documentation in the file regarding camera/video monitoring for R1's room. Based on record review, interviews conducted, and observations made, these allegations are Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 21-AS-20250729125340

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Aug 2, 2025

*Amended* 87608 Postural Supports:(a)...supports may be used...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of...hands or feet. (B) Bed rails that extend the entire length...prohibited except for residents currently receiving hospice care...This requirement was not met as evidenced by: Based on records, observations, and interviews, Licensee did not comply with the section cited above. R1 had a gait belt around their wheelchair and two half bed rails as a full bed rail. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: *Amended* Licensee removed secondary bed rail during LPA visit. LPA also observed gait belt on R1's wheelchair was removed during visit. Deficiency cleared during visit. Licensee to request from R1's physician to have a half bed rail order for mobility and submit proof of order. Licensee to submit In-Service training for all staff reviewing Postual Support Regulation. Training to include Topic, Date, Trainer,Staff Job Roles,and Signatures. Proof of Physician Order and In-Service Training to be submitted to CCL for review and approval by POC due date of 08/15/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 15, 2025

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 was not met as evidenced by: *Amended* Based on interviews conducted, Licensee did not comply with the section cited above. R1 has a camera in their room without the written approval/consent of the Department or R1's Responsible Party. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Licensee to immediately remove camera from R1's room and submit proof to CCL by POC due date of 08/15/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Aug 15, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a)...residents...shall have all of the following personal rights:(6) To make choices concerning their daily lives in the facility. This requirement was not met as evidenced by: Based on interviews, Licensee did not comply with the section cited above. R1 stated that they go to bed earlier than they prefer and are also unable to get out of bed on their own. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Licensee to submit In-Service training for all staff reviewing all regulations on the Personal Rights of Residents. In-Service Training to be submitted to CCL for review and approval by POC due date of 08/15/2025.

Type of visit: Required - 1 Year

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with House Manager, Helen Hocog. Licensee/Administrator, Harry Van Meines, arrived during visit at approximately 10:45AM. Facility is a Residential Home for the Elderly and provides care and assistance for Older Adults. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 6 residents in care, and 3 staff members on-site. At approximately 9:50AM, LPA reviewed the Facility's Staff Roster and all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, 1 staff room, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguisher was last inspected December 2023. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted October 2024. At approximately 10:50AM, LPA reviewed staff files, resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure. Administrator's Certificate for Henry (Harry) Van Meines (7020155740) was current with an expiration date of 08/18/2025. Continued on LIC809 Continued from LIC809 LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 12/19/2024. Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Case Management - Incident

At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit, and met with House Manager, Helen Hocog. Licensee/Administrator, Henri (Harry) Van Meines, was available by telephone. The purpose of the visit was to obtain documents related to an incident report that was submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 09/24/2024. Report states that on 09/24/2024, Staff Member 1 (S1) informed Licensee/Administrator that Staff Member 2 (S2) was abusive to Residents 1 and 2 (R1 and R2) in 2023. Report continues to state that S2 was terminated in April 2023 and is no longer an employee of the facility. Per discussion with Licensee/Administrator, they will be submitting an SOC-341 report to the Local Ombudsman and to the San Rafael Police Department. LPA requested that a copy be submitted to CCL. LPA requested and reviewed documents. No Deficiencies cited during visit. Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to House Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 24, 2024

Type of visit: Required - 1 Year

10/20/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by House Manager, Helen Hocog. Administrator, Henri Van Meines was contacted and arrived later in the visit. The facility is licensed for six non-ambulatory residents and a hospice waiver for six. The facility currently provides care for six residents, three of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with House Manager, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia tested and found to be in working order. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/8/2022. Both smoke detectors and carbon monoxide detectors throughout the facility were interconnected, tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under the kitchen sink, laundry closet and storage in the garage. During inspection, LPA observed three storage sheds located in the side yard to be unsecured. Residents were not directly in access but LPA and Administrator discussed compliance. Technical Violation issued. Residents were observed engaging in discussion with staff, watching television shows or resting in their bedrooms. Residents appear to have a positive relationship with staff based on LPA observations. Continued onto LIC809-C There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications are stored in a designated medication cart located in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found residents to have updated Physician's Reports, Needs & Service and Hospice Care Plans. During a review of staff files LPA found two staff requiring updated 1st Aid & CPR certification. Certification recently expired and facility has attempted to contact training services but pending scheduling. Technical Violation issued. Upon review of staff association on Caregiver Background Check roster LPA found that staff S1 is currently pending for clearance. S1 is currently associated and cleared for another residential care facility. Administrator has reached out to the Department and will be completing a Background Transfer Request and submit to the Regional Office. Technical Advisory. Administrator, Henri Van Meines's Administrator Certificate 6053350740 is currently pending for renewal. LPA confirmed on CCLD Pending Application list that the certification application payment and training was received as of 5/16/2023. LPA requested the following documents be sent to CCL by COB 11/20/2023: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance Control of Property No deficiencies cited.the state’s words, verbatim · CDSS document, Oct 20, 2023