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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:13:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20210818134552
FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Francisca RecedeTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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 Staff left resident in soiled diapers for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint investigation visit regarding the above noted allegation. At 10:15 am LPA Urena arrived at the facility, met with Administrator Francisca Recede and explained the reason for the visit.
On 08/25/2021, at 2:30pm the LPA interviewed Staff 1(S1), Staff 2(S2), and Administrator.
Regarding the allegation: Facility does not have a log to document time of diaper change and may not be assisting residents with diaper change, based on the information gathered during interview with staff. Staff stated that residents are changed three times a day. Morning, noon, and evening, before residents are out for the night. The following deficiencies were cited per Title 22, see attached LIC9099-D.
Based on the interviews with staff there is sufficient evidence to support the claim that staff left resident in soiled diapers for an extended period of time, more than the allotted time per regulations. Therefore, this allegation is deemed Substantiated at this time.
Citation was issued. Exit interview conducted, today's report and appeal rights were reviewed and issued. Signatures were obtained. Report was issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20210818134552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
87625(b)(2)
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87625b(b) (2)-Managed Incontinence
In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:

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Licensee has agreed to create a daily log for diaper change for each resident, and staff must document and make entries for each diaper change .
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(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/18/2021 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20210818134552

FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
09/22/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Francisca RecedeTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Resident sustained unexplained bruises while in care.
Staff refused to assist resident with meals.
Staff did not attend to resident in a timely manner.
Licensee did not make resident’s records available to resident's responsible person.
Staff cut resident's hair without the consent of the responsible person.
INVESTIGATION FINDINGS:
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This report was amended. Please refer to the report issued on 3/30/2022 for the report.



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210818134552
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A HEAVENLY HAVEN, INC.
FACILITY NUMBER: 197605522
VISIT DATE: 09/22/2021
NARRATIVE
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This report was amended. Please refer to the report issued on 3/30/2022 for the report.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4