197610624-12-16-2025-31-AS-MAGN-DPEMFC-20251216083406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610624
Report Date: 12/15/2025
Date Signed: 12/16/2025 08:34:26 AM

Document Has Been Signed on 12/16/2025 08:34 AM - 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:	HAVENS CREATION INCORPORATION		FACILITY NUMBER:	197610624
ADMINISTRATOR/ DIRECTOR:	GAFAR, LATEEF SOLA		FACILITY TYPE:	735
ADDRESS:	9529 CORBIN AVE		TELEPHONE:	(678) 949-1359
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 4		CENSUS: 0	DATE:	12/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:10 PM
MET WITH:	Adeleye Sotimehin- Licensee		TIME VISIT/ INSPECTION 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) Mariana Agban conducted an announced Annual Required visit and inspection of the facility. The facility currently has zero clients. LPA met with Adeleye Sotimehin Editha, and at approximately 12:20 p.m., with the Licensee's assistance, LPA took a tour of the physical plant. Required postings were observed in the dining area. LPA tested the smoke alarms and carbon monoxide detectors, and they were functional. LPA observed a fire extinguisher with the date of purchase 12/15/25. LPA observed the kitchen to be clean, and the kitchen appliances are functional. Sharp objects were stored in a locked cabinet. LPA found a sufficient amount of perishable and non-perishable food at the facility, properly stored. Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to seat the capacity of the facility. Seating, such as couches, where in good repair and seats the capacity of the facility. There is a fireplace that is properly screened. The fireplace is non-functional. No key to the fireplace, and fireplace tools were not present. The laundry area is located adjacent to the kitchen. The washer and dryer appeared to be functional. All toxins are locked in the laundry cabinet. Office Room: had the Administrator's office. LPA observed locked cabinets where the staff documents are stored, and for future clients. Bedrooms: There are four (4) bedrooms in the facility. All four (4) bedrooms are designated for private use. All bedrooms were furnished with appropriate bedding and linens and had sufficient lighting. Bathrooms: There are two (2) bathrooms designated for clients' use. Hot water temperature was measured from the bathroom sink at 106.4 and 110.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. There was a one-half(1/2) bathroom for staff use by the laundry area. (Continue on 809C)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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: HAVENS CREATION INCORPORATION	FACILITY NUMBER: 197610624
	VISIT DATE: 12/15/2025

NARRATIVE

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Surrounding Grounds: There was furniture appropriate for outdoor use. The gates at both sides of the home were checked to ensure no locks were installed and that exits and passageways were clear for emergency evacuation.
Temperature: Facility maintains a comfortable temperature of 67 degrees Fahrenheit.
Medication: The medication will be kept in a locked cabinet in the entry area.
Garage: LPA observed storage boxes in the garage. The garage is used only for storage.
Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms.

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.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC809 (FAS) - (06/04)

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