Petani Haven

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building. There are client bedrooms--two are occupied as private rooms--a staff room, 2 full bathrooms, living/dining room, TV room, and kitchen. Washer and dryer are located in 1-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 113 degrees in rear client bathroom. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, however, staff records are not available for review. Ane Haupeakui and Esther Hunkin oversee facility operations; Esther Hunkin's RCFE administrator certificate expires 8/27. The following licensing forms are requested to be completed and submitted to CCLD BY 2/3/26: - Designation of Administrative Responsibility (LIC308) - Personnel Report (LIC500) - page 9 of revised Emergency Disaster Plan (signed and dated) - Facility Sketch (LIC999), including dimensions - Proof of current liability insurance Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.the state’s words, verbatim · CDSS document, Jan 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Jan 20, 2026

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as hospice client #2 has full bed rails, but this is not included in hospice care plan. Licensee failed to ensure that full bed rails are included in hospice care plan, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Copy of hospice care plan for client #2--including full bed rails order--was provided during visit. Deficiency corrected and cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(6) · Plan of correction due date: Jan 20, 2026

INCIDENTAL MEDICAL CARE 87465 A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as medications for 3 residents are not recorded on Centrally Stored Medications Records. Licensee failed to ensure that medications for clients are logged on CSMR, which poses a potential health or safety risk.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Clients' medications were logged on CSMR in LPA's presence. Deficiency corrected and cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Feb 3, 2026

ALTERATIONS TO BUILDINGS/GROUNDS Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met, as rear family room has been extended almost 8 feet, but there is no approved building permit. Licensee failed to maintain approved building permit, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Jan 27, 2026

MEDICAL ASSESSMENT Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met, as there are no MD reports for clients #3 and #4. Licensee failed to ensrue that MD reports are maintained prior to admission and maintained, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Copies of MD reports for clients #3 and #4 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(g) · Plan of correction due date: Jan 21, 2026

PERSONNEL RECORDS All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met, as there are no staff records available for review. Licensee failed to ensure that staff records are maintained at facility, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Jan 27, 2026

PREADMISSION APPRAISAL Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs. This requirement is not met, as there are no appraisals on file for all residents. Licensee failed to ensure that appraisals are maintained for all clients, with poses a potential health, safety or personal rights risk to clients in care. No preadmission appraisals for clients #3 and #4 and no appraisals for clients #1 and #2the state’s words, verbatim · CDSS document, Jan 20, 2026

Plan of correction: Copies of appraisals for all 4 residents will be sent to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 3 shared client bedrooms--only 2 are occupied as private rooms--a staff room, 2 full bathrooms, living/dining room, TV room, and kitchen. Washer and dryer are located in 1-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 116 degrees in rear client bathroom. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Ane Haupeakui and Tomasi Haupeakui oversee facility operations; Tomasi's RCFE administrator certificate expires 2/25. As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895. The following licensing forms are requested to be completed and submitted to CCLD BY 2/25/25: - Designation of Administrative Responsibility (LIC308) - Personnel Report (LIC500) - Emergency Disaster Plan (revised 9 page LIC610-E signed and dated on page 9) - Facility Sketch (LIC999), including dimensions - Proof of current liability insurance Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Note. Facility is not in compliance with Section 87470 Infection Control Plan: An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (A) Identification of a staff position to perform the duties of an Infection Control Lead for the facility. 1. Contact information for the designated Infection Control Lead shall be made available to the department upon request. 2. A description shall be included of how the Infection Control Lead shall be trained by a medical professional, local health official, health department, or other research-based medical authority that provides infection control training that will include enforcement of the Infection Control Plan. (B) A description of how the licensee shall meet the specific infection control practice requirements of subsections (a), (b) and (d). (C) An Infection Control Training Plan. 1. Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with residents. 2. Ongoing training requirements for all facility staff shall be addressed by the plan, with training to be provided by the Infection Control Lead. 3. The description of initial and ongoing training shall address the requirements of subsections (a), (b) and (d). (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. (E) The licensee shall ensure that staff encourage residents to follow infection control practices as necessary.the state’s words, verbatim · CDSS document, Feb 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Feb 25, 2025

PRE-ADMISSION APPRAISAL 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. This requirement is not met, as there are no appraisals maintained for both hospice clients. Client #1 admitted 7/2023 & client #2 admitted 9/2024. This was cited in 2024. Licensee failed to ensure appraisals are completed for clients, which poses a potential health, safety or personal rights riskthe state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Copies of signed and dated appraisals for clients #1 and #2 will be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Feb 25, 2025

PERSONNEL REQUIREMENTS-GENL Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as there is no documentation maintained that all staff have current first aid training. Licensee failed to maintain evidence that caregivers have required first aid training, which poses a potential health, safety or personal rigjts risk to clients in care. This was cited in 2024 and subsequently corrected.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Proof of current first aid training for staff to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Feb 25, 2025

HEALTH AND SAFETY CODE A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. - tThere is no record of disaster drillsthe state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87470(c)(A-E) · Plan of correction due date: Feb 25, 2025

INFECTION CONTROL PLAN See page 2 for regulation text. This requirement is not met, as there is no Infection Control Plan maintained. This poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Licensee to complete LIC9282 and send a copy to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 19, 2025

CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to HSC Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: obtain a CA clearance or a criminal record exemption as required by the Department This requirement is not met as staff #1 is present at facility, but has not yet obtained criminal record clearance. Licensee failed to ensure that all staff have criminal record clearance prior to working with clients. This poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 18, 2025

Plan of correction: Staff #1 will resubmit fingerprints in order to obtain criminal record clearance. Licensee must follow up to associate criminal record clearance to facility and submit proof of correction to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 3 shared client bedrooms, a staff room, 2 full bathrooms, living/dining room, TV room, and kitchen. Washer and dryer are located in 1-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Ane Haupeakui and Tomasi Haupeakui oversee facility operations; Tomasi's RCFE administrator certificate expires 2/25. As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895. Proof of current liability insurance is given to LPA today. The following licensing forms are requested to be completed and submitted to CCLD BY 2/27/24: - Designation of Administrative Responsibility (LIC308) - Personnel Report (LIC500) - Emergency Disaster Plan (revised 9 page LIC610-E signed and dated on page 9) - Facility Sketch (LIC999) Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Advisory Notes--5 pages.the state’s words, verbatim · CDSS document, Feb 13, 2024