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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606737
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:44:01 PM


Document Has Been Signed on 06/20/2024 01:44 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., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:A HEAVENLY HAVEN, INC. IIFACILITY NUMBER:
197606737
ADMINISTRATOR:FRANCISCA RECEDEFACILITY TYPE:
740
ADDRESS:20000 LASSEN STREETTELEPHONE:
(818) 775-9397
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Francisca Recede, Administrator TIME COMPLETED:
02:10 PM
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At 12:30pm, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit.

At 12:35pm LPA conducted a tour of the physical plant and observed the following:
Facility has six (6) bedrooms designated for resident’s use, four (4) bathrooms and one staff room (room #2). Facility is licensed for capacity of six (6) of which three (3) non-ambulatory and one (1) bedridden resident. It has also been approved for a hospice waiver for four (4) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. Facility maintains a temperature of 76°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The fire extinguisher was observed in the kitchen and the living room area and was last serviced on 02/02/24. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 112.6°F. Extra towels and linens were readily available. Laundry area is also located by the kitchen area and LPA observed all chemicals and detergents are kept locked and inaccessible to residents. At 1:10pm, smoke detectors and carbon monoxide monitors were tested and observed to be functional. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 1:15pm to 2:00pm, LPA reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.
No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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