Residential Care Services Investigation Summary Report

Provider/Facility: ANGEL'S HAVEN (687969) Intake ID(s): 3392044

License/Cert. #: AF750508Investigator: Osterman, Pamela Region/Unit: RCS Region 2/Unit G Investigation

Date(s):07/25/201708/14/2017

through

Complainant Contact Date(s): 07/25/2017Allegations:#1. Named resident was seen hitchhiking off highway. The AFH provider was not at the home.

Investigation Methods:Sample: residents, including

named resident (NR)Observations: AFH: observed provider

and residents in thehome. NR sitting outsidein a chair. Front and backdoorbell button did notring.

Interviews: providerresidents, (NR)others not affiliated withthe AFH

Record Reviews: AFH: negotiate care plan(NCP),assessment, police report

Allegation Summary:#1. On AFH tour , the department staff observation found residents including (NR) sitting outside, and provider in the home. NRsaid likes to leave the AFH and walk to friends house to get One current resident said they don't know whensomeone comes to the door. Others not affiliated with the AFH said it was difficult to access the home. Others said around 8 pma person answered door saying the owner was not at home. The provider said that on 7-24-17 they answered the door around 8pm when one resident returned from an outing.

Record review showed on NCP "supervise NR when going outside." Assessment showed "resident gets lost outside. Record ofpolice report showed around 9:20 p.m. no one answered the door and others said the AFH doorbell did not ring. Observed thefront and back doorbells did not ring.

Unalleged Violation(s): Yes No

Page 1 of 2

Residential Care Services Investigation Summary Report

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See statement of deficiencies SOD dated 8-14-17.

Page 2 of 2

Completion DateLicense #: 750508

October 20, 2017

6Page 6of

ANGEL‘S HAVENPlan of Correction

Statement of Deficiencies

Licensee: YOLI ARRIOLA

Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active measures

to correct this deficiency. By taking this action, ANGEL'S HAVEN is or will be in

compliance with this law and / or regulation on (Date)________________ . In addition, I

will implement a system to monitor and ensure continued compliance with this cited

deficiency.

Provider (or Representative) Date