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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200746
Report Date: 07/03/2024
Date Signed: 07/03/2024 11:54:17 AM

Document Has Been Signed on 07/03/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HAVEN HOMEFACILITY NUMBER:
019200746
ADMINISTRATOR/
DIRECTOR:		GONZALES-BANSIL, MAEFACILITY TYPE:
735
ADDRESS:8695 WICKLOW LANETELEPHONE:
(510) 220-6712
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Reynante BansilTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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On 7/03/2024 at 9:46 am, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Reynante Bansil and explained the purpose of the visit..

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 72 degree F. LPA observed lighting in all rooms are adequate for the comfort and and safety of the clients. Hot water temperature in the shared clients bathroom was measured at 109 degree F. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. The supply of extra hygiene was available. for clients. There is a minimum of one-week supply of non- perishables and 2 -day perishables food supply.

Smoke Detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was serviced on 10/25/2023. Emergency disaster plan was last posted on 01/15/2020. First aid kit was observed to be complete. Fire drill was last conducted on 06/15/2024.

At 10:25 am, LPA reviewed 5 clients records and 5 staff records and all were complete. at 10:55 am, clients medications were reviewed.

No deficiencies were cited during this inspection. Exit interview conducted and a copy of the report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Ardalan Gharachorloo
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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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