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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610721
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:38:25 PM

Document Has Been Signed on 02/20/2025 01:38 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:HAVEN OASIS SENIOR LIVING, INCFACILITY NUMBER:
197610721
ADMINISTRATOR/
DIRECTOR:		PAMONO, HANANIAHFACILITY TYPE:
740
ADDRESS:8032 GLADE AVETELEPHONE:
(310) 903-2453
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 0DATE:
02/20/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Pramono Hananiah-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 2/20/25 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Pramono Hananiah. Upon arrival, LPA introduced herself by showing her badge. This is a single story house which will be operating as Residential Care Facility for Elderly (RCFE). The Application to operate the RCFE was received by Community Care Licensing (CCL) on November 15th, 2024. A fire clearance was approved on January 9th, 2025, for six (6) Non-Ambulatory residents of which one (1) may be Bedridden for bedroom #1. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has one (1) fire extinguisher that was purchased on 12/21/2024 and is located on the wall next to the kitchen cabinet.
A tour of the physical plant was initiated at approximately 10:45am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked inside kitchen cabinet next to the refrigerator and chemicals observed stored inside locked cabinet under the kitchen sink. Kitchen area is open plan facing both dining and living areas.

BEDROOMS: The facility has four (4) bedrooms and all bedrooms are designated for residents' use. All residents' bedrooms observed to be nicely furnished with beds, night stands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and a closet space. Additional linen is available inside each bedroom’s closet and inside the linen cabinet located in the hallway.

BATHROOMS: The facility has two (2) bathrooms, both designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels and washing hands signs. The hot water delivered in the bathrooms measured at 11:10am to be at 115 degrees.

Continue On LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: HAVEN OASIS SENIOR LIVING, INC
FACILITY NUMBER: 197610721
VISIT DATE: 02/20/2025
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COMMON AREAS: These include living room and a dining room. The living room was equipped with new furniture, a television, and chairs. There is an electric fireplace in the living room area. The dining area has a dining table to accommodate six (6) clients. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 11:15am to be at 69 degrees F.

Office/Activity room: Facility has separate activity/resting room located next to the kitchen. LPA observed a cabinet with various activity supplies nicely stored and ready for residents' use. The office area is furnished with office desk, cabinets, printer and other required office supplies.

GARAGE: The garage is currently being used as storage for facility equipment, supplies and water. Garage is attached to the facility and has access from the dining area.

LAUNDRY ROOM: The washer and dryer is located in a garage. Laundry chemicals are also kept in the laundry area which is always locked and under supervision.

MEDICATIONS: Medications will be kept inside locked cabinet located in the office which is next to the activity room area. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current. Licensee/ Administrator might move and store medications in the kitchen area inside locked cabinet.
Client/Staff Files: All files and documents will be kept locked in the office area.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) clients. LPA observed locked Spa located in the backyard. Administrator confirmed it will always stay locked and under supervision.

LPA observed the facility is clean, safe and sanitary. All window screens were in good repair. Auditory signals were installed on exit doors. All passageways were free of obstruction.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HAVEN OASIS SENIOR LIVING, INC
FACILITY NUMBER: 197610721
VISIT DATE: 02/20/2025
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In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

An emergency exit plan/sketch along with other posting requirements were available and posted on the wall.



No deficiency cited on today’s visit.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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