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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201144
Report Date: 11/14/2022
Date Signed: 11/14/2022 03:03:06 PM


Document Has Been Signed on 11/14/2022 03:03 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:HEAVEN PLACE CARE HOMEFACILITY NUMBER:
019201144
ADMINISTRATOR:ADAMS, JACQUELINEFACILITY TYPE:
740
ADDRESS:14724 PEPPERDINE STTELEPHONE:
(925) 216-4129
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 0DATE:
11/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:22 PM
MET WITH:Jackie Adams, AdminstratorTIME COMPLETED:
03:10 PM
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On 11/14/22 at 1:20 PM, Licensing Program Analyst (LPA) G. Clark arrived to conduct pre-licensing inspection. LPA met with Administrator, Jackie Adams and explained the purpose of the visit. The facility currently has no residents/clients.

LPA toured facility including but not limited to: bedrooms, bathrooms, kitchen, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 70 degrees F and hot water temperature was maintained at 113.7 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was last serviced on 02/23/22.

LPA Greg Clark conducted a face to face Component III presentation on 11/14/22 starting at 1:45 p.m. LPA met with licensee/administrator.

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed the participant gained knowledge about running and maintaining the facility in accordance with regulations.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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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