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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201410
Report Date: 10/15/2024
Date Signed: 10/15/2024 06:15:05 PM

Document Has Been Signed on 10/15/2024 06:15 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HAVEN OF WALNUT CREEK, LLC, THEFACILITY NUMBER:
079201410
ADMINISTRATOR/
DIRECTOR:		GOLUB, JUVYFACILITY TYPE:
735
ADDRESS:560 DOVER DRTELEPHONE:
(925) 954-1865
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 5DATE:
10/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Applicant Juvy GolubTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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On 10/15/2024 at 2:00 PM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct a Prelicensing inspection. Upon entry into the facility, the LPAs informed Facility Manager Rahanat Abubakar of the purpose of the visit. The Applicant Juvy Golub arrived at approximately 3:10 PM.

The LPAs toured the facility with Ms. Abukar and Ms. Goub. The LPAs inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. No body of water was on the facility grounds. Medications are centrally stored. Personnel, client, and facility records were stored at the facility and made accessible to the LPAs. Bathrooms and showers were observed to be fully functioning and clean. Carbon monoxide and smoke detectors operational and the fire extinguishers were last serviced on 08/26/2024.

The fire clearance is for 6 ambulatory. However, the 5 consumers are non-ambulatory, as will be the future consumers. For that reason, the facility did not pass the pre-licensing inspection.

Exit interview conducted and a copy of this report provided to the applicant.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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