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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610624
Report Date: 11/18/2024
Date Signed: 11/18/2024 03:11:42 PM

Document Has Been Signed on 11/18/2024 03:11 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HAVENS CREATION INCORPORATIONFACILITY NUMBER:
197610624
ADMINISTRATOR/
DIRECTOR:		GAFAR, LATEEF SOLAFACILITY TYPE:
735
ADDRESS:9529 CORBIN AVETELEPHONE:
(678) 949-1359
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 0DATE:
11/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Lateef GafarTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with facility Administrator Lateef Gafar and Licensee Adeleye Sotimehin. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on May 02, 2024. A fire clearance was approved on September 4, 2024, for a maximum capacity of two (2) Non-ambulatory and two (2) ambulatory adults.


A tour of the physical plant was initiated at 9:45 am and the following was observed:
KITCHEN: The facility has a Kitchen area equipped with a refrigerator, oven, and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of four (4) clients. BEDROOMS: There are four (4) bedrooms designated for clients use. All four bedrooms are designated for private use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space. LPA observed the office room that will be used by staff only. BATHROOMS: The facility has two (2½) bathrooms. Bathroom 1 is the main bathroom and is located in the hallway. Bathroom 2 is located in Bedroom#2 and it is for private use. The hot water temperature was measured at 111.2 F and 109.8.F No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining room, which were equipped with furniture, a television, two sofas, and a chair. There is a fireplace with a screen and a glass slide. It is non-operational. No fireplace tools or fixtures are present. The dining area has a dining table accommodating four (4) clients. There were no visible immediate hazards. Required postings were observed in the dining area. LPA also observed and tested fire alarms and carbon monoxide and they were properly functioning. The fire extinguisher is also located in the dining area. The purchase date is 11/18/24. Temperature: Facility maintains a comfortable temperature of 67 degrees Fahrenheit. Laundry Area: The laundry room is located through the kitchen. The washer/dryer appears to be in good condition. Laundry supplies will be kept inaccessible in locked cabinets. (Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVENS CREATION INCORPORATION
FACILITY NUMBER: 197610624
VISIT DATE: 11/18/2024
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MEDICATION: The medication will be kept in a locked cabinet in the entry area. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool/body of water. Garage: LPA observed storage boxes in the garage. Garage is used only for storage.


In addition to the Pre-Licensing inspection, a Component III PowerPoint presentation was also held.
Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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