197610327-11-2-2023-31-AS-MCAA-CX7TA8-20231102143307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610327
Report Date: 11/02/2023
Date Signed: 11/02/2023 02:33:12 PM

Document Has Been Signed on 11/02/2023 02:33 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:	HAVEN HOMES		FACILITY NUMBER:	197610327
ADMINISTRATOR:	HOROWITZ, JESSICA		FACILITY TYPE:	740
ADDRESS:	10507 ANDASOL AVE		TELEPHONE:	(818) 324-7536
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 4	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Jessica Horowitz		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Jessica Horowitz, and explained the reason for the visit. At approximately 12:20pm, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. The carbon monoxide detector is installed in the living room. It functions properly. The fire extinguisher located in the kitchen is brand new and fully charged. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There are four (4) bedrooms designated for residents' use. All four bedrooms, occupied by the residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 120 degrees Fahrenheit. LPA did not observe and cleaning supplies or hazardous items stored in either of the bathrooms in use by the residents. Common Areas: These included the living room and dining area. The common areas were properly furnished. The living room and dining room floors were clean and in good repair. The dining room table is large enough to accommodate up to six residents. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAVEN HOMES	FACILITY NUMBER: 197610327
	VISIT DATE: 11/02/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located by the kitchen. LPA did not observe detergents to be accessible at the time of the visit. Staff room/staff work station, where medications, staff and resident records, is located adjacent to the kitchen and laundry area. Staff room is inaccessible to the residents in care.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

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

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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