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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200746
Report Date: 08/05/2022
Date Signed: 08/05/2022 01:00:36 PM

Document Has Been Signed on 08/05/2022 01:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HAVEN HOMEFACILITY NUMBER:
019200746
ADMINISTRATOR:GONZALES-BANSIL, MAEFACILITY TYPE:
735
ADDRESS:8695 WICKLOW LANETELEPHONE:
(510) 220-6712
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 6DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jeff Magadia, DSP TIME COMPLETED:
01:15 PM
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On 8/5/22 at 11:40 AM, Licensing Program Analysts (LPAs) K. Nguyen and L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Direct Support Professional (DSP), Jeff Magadia and explained the purpose of the visit. Administrator was not available during the visit. Administrator gave verbal permission for LPAs to deliver the report to DSP Jeff.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

During record review, LPAs reviewed a sample of 3 staff records and observed 3 of 3 have health screening with TB test on file.

Report continue on LIC 809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HAVEN HOME
FACILITY NUMBER: 019200746
VISIT DATE: 08/05/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 8/12/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610D Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

Exit interview conducted. A copy of this report is provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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