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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608562
Report Date: 03/28/2022
Date Signed: 11/02/2022 12:34:11 PM


Document Has Been Signed on 11/02/2022 12:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/02/2022 12:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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****This is an amendment to the attempted annual report on 03/28/22. This amendment supersedes the original attempted annual report. This report was amended to delete LPA’s conversation with Regional Center ****


On 3/28/22 at 12:05 p.m., Licensing Program Analyst(LPA) Jewel Baptiste attempted to conduct an unannounced annual required visit to Senior Haven's LLC. Upon arrival, LPA observed lawn outgrown/unkempt and debris in the front yard.

LPA proceeded to knock on the door, but no one answered. LPA did hear a dog and birds inside the home. LPA contacted facility numbers on file (818)843-3572 and (818) 281-9439 three times each and left a message describing the reason for the visit.

LPA then proceeded to call Licensing Program Manager(LPM) Lisa Hicks to update her on the situation. LPA took photos and recorded a video of the front lawn.

At 2:57 p.m., LPA contacted Lanterman Regional Center representative Sonia Garibay at (213)252-4904 to gain additional information about the facility.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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