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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605522
Report Date: 12/01/2021
Date Signed: 12/02/2021 08:24:01 AM

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. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
12/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Francisca RecedeTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Elsie Campos conducted a Case Management visit after observing deficiencies during LPAs’ complaint investigation visit on complaint number 29-AS-20211124165217. 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. Administrator indicated she did not notify Community Care Licensing (CCL) of the changes to the facility.

In addition, while interviewing facility staff at 12:36 p.m., it was revealed that Staff 1 sleeps on the couch in the family room at night.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit. (See 809-D) Exit Interview Conducted / Appeal Rights and a copy of this report has been issued.

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.
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2021
Section Cited

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87208 Plan of Operation. (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the
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services to residents shall be submitted to the licensing agency for approval.
This requirement is not met as evidenced by:

The facility is undergoing remodeling which was not reported to CCL, which poses a potential health and safety risk to residents in care.
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Type B
12/08/2021
Section Cited

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87307 Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
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This requirement is not met as evidenced by:

Facility staff indicated Staff 1 sleeps on the family room couch at night, which poses a potential 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
LIC809 (FAS) - (06/04)
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