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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 12/01/2021
Date Signed: 12/02/2021 08:29:00 AM

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
11/24/2021 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20211124165217
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:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Francisca RecedeTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility floors are in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Teresa Camara and Elsie Campos conducted an initial complaint investigation visit. LPAs met with Administrator Francisca Recede and explained the reason for the visit.

LPAs met with staff and conducted a facility tour at 10:35 a.m. LPAs observed the carpet in the facility was being removed and replaced with wood laminate flooring in the hallways, living room, family room, dining room and bedrooms. Approximately two-thirds of the facility flooring has already been replaced. LPAs observed large gaps in portions where the flooring is still being installed. In addition, construction trash was observed in the backyard. Administrator indicated the contractors should be finished in approximately one more week.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. (See 9099-D) Exit Interview Conducted / Appeal Rights and a copy of this report has been issued by email to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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 3
Control Number 29-AS-20211124165217
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: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation. (a) he facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator will secure the areas which pose tripping hazards as well as the construction trash in the yard and provide photos of this to CCL by 12/02/21.
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This requirement is not met as evidenced by:

The facility carpet is being replaced with flooring and large gaps were observed, in addition there was a large amount of construction trash in the backyard, which posed an immediate health and safety risk to resident in care.
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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: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3