197605522-6-8-2022-29-AS-ECAS-CF7U5K-20220608151651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605522
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:17:40 PM

Document Has Been Signed on 06/08/2022 03:17 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A HEAVENLY HAVEN, INC.		FACILITY NUMBER:	197605522
ADMINISTRATOR:	FRANCISCA M. RECEDE		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 713-0447
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 4	DATE:	06/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Yuliya Asatryan		TIME COMPLETED:	03:25 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with staff Aguilon ‘Auggie’ Florencio and explained the reason for the visit. Administrator Yuliya Asatryan arrived shortly thereafter.

The LPA toured the physical plant areas inside and outside at approximately 1:35 p.m., with staff Auggie, to ensure that there are no health and safety hazards.

BEDROOMS: There are (5) bedrooms designated for resident use and (1) bedroom designated for staff use. Bedroom #1, #2, #3 and #4 are single occupancy with exits to the exterior. Bedroom #6 is a shared room containing two beds, a shared closet space, a shared drawer chest with outdoor access. Bedroom # 5 is a staff bedroom. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use.

BATHROOMS: The facility has (2) shared bathrooms located in adjacent hallways. The bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Bathroom hot water measured between 111.9 degrees Fahrenheit and 116.6 degrees Fahrenheit between 1:50 p.m. and 1:55 p.m.

KITCHEN: At 1:45 p.m., the LPA toured the Kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, centrally stored medications, and chemicals were locked and inaccessible to residents in care at the time of the visit. Kitchen hot water measured at 108.6 degrees Fahrenheit at 1:57 p.m.

Continued on LIC 809-C.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

DINING ROOM/LIVING ROOM/COMMON AREAS: At 1:58 p.m., the LPA toured the dining, living room and common areas. The LPA observed it to be free and clear of any obstructions or tripping hazards. The facility uses this space for activities and dining. All areas and furniture were clean, sanitary and in good repair. The LPA observed a screened fireplace in the living room. The administrator confirmed that living room area is not a sleeping quarters and is used for relaxation, visitation for residents. At approximately 2:00 p.m. smoke and carbon monoxide detectors were observed throughout the facility. At 2:01 p.m. staff tested the fire alarm system and the LPA observed it to be operating appropriately in all bedrooms and common areas at the time of the visit. The fire extinguisher was observed to be full and last serviced on 3/31/2022. All doors have working and active auditory devices.

BACKYARD: At 2:04 p.m. the LPA toured the backyard area. The backyard has a covered outdoor area equipped with furniture for resident use. Furniture was observed to be in good repair. There were no bodies of water noted. The LPA observed a locked shed in the backyard containing cleaning supplies, additional personal protective equipment, incontinence supplies, a freezer containing additional frozen foods and a cabinet with additional non-perishable foods.

INFECTION CONTROL: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. There was an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The LPA reminded the Licensee that masking protocols are still in place including vaccination requirements, visitation, and testing protocols.

No deficiencies were noted at this time. Exit interview conducted. A copy of this report discussed and provided via email to the Administrator, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2