197608562-4-2-2025-31-AS-NSHN-DFCTDY-20250402143907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608562
Report Date: 04/02/2025
Date Signed: 04/02/2025 02:39:36 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/02/2025 02:39 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SENIORS' HAVEN LLC		FACILITY NUMBER:	197608562
ADMINISTRATOR/ DIRECTOR:	JORGE ADLE MENDOZA		FACILITY TYPE:	740
ADDRESS:	1831 NORTH KENWOOD STREET		TELEPHONE:	(818) 843-3572
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/02/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Jorge Adle Mendoza - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and inspection of the facility. LPA met with Jorge Adle Mendoza - Administrator and explained the reason for the visit. The facility is licensed to serve six (6) residents ages 60 and above, of whom (6) may be non-ambulatory. Bedroom #3 has an approved waiver for two (2) hospice residents. Currently the facility has no clients in care.

At 10:45am, with the assistance of Administrator, LPA took a tour of the physical plant. The facility is a one story structure with four (4) bedrooms, two (2) bathrooms, kitchen, dining area, family room, and living room/office area. Required postings were observed in the entry area. The smoke alarms/carbon monoxide detectors are hardwired and interconnected. At 11:05 am smoke alarms/carbon monoxide detectors were tested and observed to be functional. The fire extinguisher is located in the kitchen and was purchased on 7/1/2024. The auditory alarms on all exit doors were functional at the time of the visit.

Common Areas: These included the living room, family room and dining area. LPA observed a double sided fireplace in the family and living rooms; both fireplaces were properly covered by a glass cover. The common areas were properly furnished with tables and chairs for the number of residents.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a locked drawer in the kitchen. Chemicals and detergents were stored in a locked cabinet underneath the sink.

Continued on LIC 809-C

Eva Miller	TELEPHONE: (818) 596-4373
Nadia Shahbazian	TELEPHONE: (818) 476-6033
	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SENIORS' HAVEN LLC	FACILITY NUMBER: 197608562
	VISIT DATE: 04/02/2025

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Bedrooms: There were four (4) bedrooms, three (3) of which are designated for residents' use. Bedroom # 3 is designated for hospice residents and bedroom #4 is designated as staff room. All bedrooms are were properly furnished with appropriate beddings, chairs, cabinets, linens and have sufficient lighting.

Bathrooms: There are two (2) bathrooms, one near bedroom# 4 and one between bedrooms #2 and #3. LPA observed functional fixtures, grab bars and non-skid mats in each bathroom. Hot water temperature was measured at 120.2 degrees Fahrenheit.

Surrounding Grounds: There were no bodies of water or obstructions on the premises. There is a covered patio with furniture appropriate for outdoor use. There is a locked shed in the backyard. The laundry machines and detergents are located in the garage, which is currently used for storage. There is a ramp leading from the living room to the backyard; there is also a side door in the kitchen and a door in bedroom# 4 leading to the backyard. Facility uses the main entry door as the emergency exit door.

Resident Files/Medications: Since there have been no residents for over two years, LPA did not review resident records. LPA observed a complete first aid kit and the manual in a locked cabinet, which is designated for medication storage.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing requirements.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies were observed during the visit.

Exit Interview Conducted / A Copy of the Report Issued to the Administrator.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Nadia Shahbazian	TELEPHONE: (818) 476-6033
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

LIC809 (FAS) - (06/04)

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