Haven Residence of San Rafael

Allegation investigated: Staff did not follow reporting requirements

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to initiate a complaint investigation regarding the above allegation and met with House Manager, Sheaena Hocog. Licensee, Harry Van Meines, arrived during visit at approximately 11:50AM. During the course of the investigation, the Department made observations. There is an allegation of "Staff did not follow reporting requirements." Per report, a staff member was punched in the face by a resident approximately 2-3 weeks ago and was reported to management and the Licensee. Report stated that it was believed that the incident was not reported to Community Care Licensing. LPA contacted the Complainant for additional information. Complainant refused to provide information such as who the resident was, when the incident occurred, and if there were any witnesses to the event. Continued on LIC9099 Unfounded Continued from LIC9099 Per Title 22 Regulations, Reporting Requirements, 87211(a)(1)(D), "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents..." Review of Title 22 Regulations indicated that an incident should be reported to Community Care Licensing if the welfare, safety, or health of a resident is threatened by a staff member or other residents in the facility. Because the incident alleged in the complaint involved a resident hitting a staff member, this incident was not necessarily required to be reported to the Department. Based on review and observation of Title 22 Regulations, this allegation is Unfounded. A finding of Unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 21-AS-20260617104728

Type of visit: Required - 1 Year

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit, Upon arrival, LPA rang the doorbell and knocked on the door multiple times. LPA contacted Licensee at approximately 8:40AM and explained that they have been waiting to be let into the facility to conduct the visit. Licensee stated they will call the house. At approximately 9:00AM, LPA was greeted by staff members, Breana Chargualaf and Sheaena Hocog. Per staff members, they usually get the residents ready for the day around this time and apologized for the wait. 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. Licensee, Harry Van Meines, arrived during visit at approximately 11:50AM. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility. LPA observed the following: Facility was found to be clean and at a comfortable temperature. Facility had emergency lighting. Facility is a one story residence with 5 resident bedrooms, two and a half bathrooms, two staff rooms, and common areas. 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 facility sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. Fire extinguisher was last inspected December 2025. Facility's last emergency/disaster drill was conducted June 2026. Facility's emergency disaster plan and infection control plan were last reviewed and updated May 2025. Facility was observed to have enough water available in the event facility had to shelter in place for 72 hours. Continued on LIC809C Continued from LIC809 During walkthrough, LPA observed that facility had multiple instances of expired or moldy foods including bread, canned goods, and drinks. LPA also discussed with Licensee and facility staff to ensure that the backyard is kept clean of pet feces. LPA observed that the laundry door exit (identified as exit door #4 in facility sketch) was obstructed by a bag of powdered laundry detergent. Per review of sketch, it is not an emergency exit for evacuation. LPA discussed with Licensee on keeping all exit doors clear. LPA reviewed staff files and resident files. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification and required annual training. Resident files had updated resident assessments and appraisals. LPA discussed with Licensee on ensuring that resident appraisals address behavioral expressions if they have been identified in resident medical assessments. Administrator's Certificate for Henri (Harry) Van Meines (7020155740) was current with an expiration date of 08/18/2027. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date to finish medication audit. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), 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, Appeal Rights discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 26, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Staff Members, Sheaena Hocog and Breana Chargualaf. Licensee/Administrator, Harry Van Meines, arrived during visit at approximately 1:00PM. 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 2 staff members on-site. At approximately 12:25PM, 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. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story residence with 5 resident bedrooms, two and a half bathrooms, two staff rooms, and common areas. 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 out of compliance with Title 22 regulations measuring over 120F (deficiency cited, LIC809D, regulation 87303(e)(2)). Fire extinguisher was last inspected November 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted April 2025. 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. Continued on LIC809C Continued from LIC809 During medication review, LPA observed that 3 of 6 residents did not have their medication centrally stored and logged as required (deficiency cited, LIC809D, regulation 87465(h)). Administrator's Certificate for Henry (Harry) Van Meines (7020155740) was current with an expiration date of 08/18/2025. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC308) Emergency Disaster Plan (LIC610E) Personnel Report (LIC500) Register of Clients/Residents (LIC9020) Updated Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 06/16/2025. 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, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 16, 2025

Type of visit: Prelicensing

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Harry Van Meines. Upon arrival, LPA was informed that there are currently no residents in care. Facility received an approved fire clearance dated 04/04/2024 that allows for six non-ambulatory clients. Facility also has a hospice waiver for 6 individuals. LPA conducted a walk-though of facility with Applicant and observed the following: Per facility sketch, facility is a one story residence with 5 resident bedrooms, two and a half bathrooms and common areas. LPA observed that facility has a storage room and staff room located in the garage that was not indicated on the facility sketch. Per conversation with the Applicant, the Fire Department approved the rooms located in the garage. LPA requested that a new facility sketch be submitted to Licensing to correctly reflect the facility's floor plan. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. 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. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. 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. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has sufficient items for cooking and eating. Facility has a locked cart located in the dining room used for centrally stored medications and files. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguisher was inspected March 2024. Facility's smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. Component III was reviewed with Applicant. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicant. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 13, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 5/31/2024, applicant/administrator participated in COMP II. Identification of the applicant / administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 31, 2024