<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320396
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:31:24 PM

Document Has Been Signed on 10/20/2023 02:31 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SAFE HAVEN ADULT HOMEFACILITY NUMBER:
198320396
ADMINISTRATOR:STOWE, YOLANDAFACILITY TYPE:
735
ADDRESS:4222 E. LINSLEYTELEPHONE:
(310) 864-5421
CITY:COMPTONSTATE: CAZIP CODE:
90221
CAPACITY: 5CENSUS: 0DATE:
10/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Administrator Yolanda StoweTIME COMPLETED:
12:15 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
On 10/20/23 at 9 am Licensing Program Analyst (LPA) Villegas conducted an announced visit to the facility for purpose of a pre-licensing evaluation, LPA met with Administrator Yolanda Stowe.

An application was submitted to CCLD on May 15th, 2023 for Initial license for an Adult Residential Facility to serve 5 adults ages 18 to 59. There is a fire clearance for five (5) ambulatory clients. Fire clearance approved on September 12th, 2023, surety bond obtained on April 5th, 2023, and a residential infection control plan has been submitted.

Facility is a single-story home located in a residential neighborhood and consist of the following; (3) bedrooms in doors, (1) large bedroom located in the detached house in the backyard, (2) shared bathrooms located indoors, (1) bathroom located in the detached house, living room, den area, a kitchen, an indoor laundry area, a covered gazebo for shade, a shed for storage, and a detached garage that houses an additional freezer and an office area. No bodies of water on property grounds, no firearms are on the property. The facility has board games, books, and other recreational materials for the client's use, commensurate with the plan of operation. Passageways, walkways, driveways, steps, and patios are free from obstructions.

The client bedrooms are spacious and will easily accommodate the client's furnishings. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in hallway linen closet. Chairs, lamps and dressers were all observed in addition to closet space.

Posted & readily available for review in den area is the emergency disaster plan, emergency phone numbers, daily schedule, activities calendar, menu, clients rights, administrator certificate and visitors policy. One (1) fire extinguisher is mounted in kitchen/den area, a second extinguisher is located inside the detached bedroom.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SAFE HAVEN ADULT HOME
FACILITY NUMBER: 198320396
VISIT DATE: 10/20/2023
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
26
27
28
29
30
31
32
Smoke and carbon monoxide detectors were observed and are operational. A landline was observed in the living room. Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer inside the linen closet. Stove burners, microwave and refrigerator are all operational. Refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezers are at (0) zero degrees F. and water temperatures measured between 105-120 degrees F.

A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in a locked drawer in the living room, available for staff use but inaccessible to clients. Cash resources will be locked and stored with P & I Ledger, accessible to designated staff. Records of staff and clients shall be stored in a locked cabinet inside office area and the section has been inspected.

Component III was conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted with Administrator Yolanda Stowe, and a copy of this report has been provided. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2