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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320522
Report Date: 07/03/2025
Date Signed: 07/03/2025 11:04:35 AM

Document Has Been Signed on 07/03/2025 11:04 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SAFE HAVEN RESIDENCEFACILITY NUMBER:
198320522
ADMINISTRATOR/
DIRECTOR:		VILLANUEVA, EDWINFACILITY TYPE:
735
ADDRESS:2012 W. WASHINGTON BLVD.TELEPHONE:
(213) 322-6297
CITY:LOS ANGELESSTATE: CAZIP CODE:
90018
CAPACITY: 21CENSUS: 0DATE:
07/03/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Edwin Villanueva - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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 07/03/2025 Licensing Program Analysts (LPA) Troy Watson conducted a pre-licensing evaluation for Safe Haven Residence an Adult Residential Care Facility. Today’s pre-licensing evaluation was conducted with the Administrator/Licensee Edwin Villanueva.

The licensee has applied for a license to serve (17) ambulatory adults and (4) non-ambulatory adults ages 18-59. The fire clearance is approved for (17) ambulatory residents and (4) non-ambulatory. The building is equipped with (16) smoke detectors, two carbon monoxide detectors and two (2) fully charged fire extinguishers with four exits for the clients. All exit doors are indicated with an exit.

A tour of the Kitchen, Dining Room, Living Room (11) bedrooms, (5) bathrooms, shaded patio area, (1) Office, and storage area upstairs with non-perishable food to last for 7 days for the clients was inspected by the LPA. Inspection of the inside and outside perimeters were conducted with the Administrator Edwin Villanueva. Storage for all PPE is on the second floor in the main facility. The storage area has extra bedding, and linen was inspected and adequately supplied for the residents. A backyard with chairs and a shaded patio area was also observed. The front and back entrance of the facility has Exit signs.

CONTINUED ON LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAFE HAVEN RESIDENCE
FACILITY NUMBER: 198320522
VISIT DATE: 07/03/2025
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
The following was observed during this visit:

MEDICATIONS

There is a locked centralized storage area for clients’ medications, personnel folders and P&I located in the office. There is also a cabinet for staff’s personnel folders.

PHYSICAL PLANT

Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, an open balcony on the second floor, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. The facility temperature is between 115.7°F. degrees and 120.6 °F. degrees. Hallways, and areas are well-lit. All (16) Smoke alarms were tested and operated properly. Carbon monoxide detectors operate properly.

BEDROOMS

All bedrooms have lamps, chairs, and sufficient lighting, mattresses, and pillows. There are 11 bedrooms in the main facility with drawers, and adequate closet space. Each room has night stands. And there is sufficient lighting in the hallway.

BATHROOMS

There are (5) bathrooms that are accessible to the residents. There are (5) showers and (5) toilets. The hot water temperature in bathrooms and kitchen is between 115.7° Fahrenheit and 120.6° Fahrenheit. All bathrooms are located next to the bedrooms.

SUPPLIES

There are clients’ personal hygiene supplies to include soap and toilet paper. There is a sufficient supply of clean linens to permit weekly changing of clients’ top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths in the second-floor upstairs storage area. The first aid kit was inspected and found to be in compliance with an emergency first aid guy with the cross symbol, tweezers, scissors, gauze and tape.

CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SAFE HAVEN RESIDENCE
FACILITY NUMBER: 198320522
VISIT DATE: 07/03/2025
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
FOOD SERVICE

The dining room is near the kitchen. The facility currently has one refrigerator, and the freezer is 10° Fahrenheit. The refrigerator is a maximum of 38° Fahrenheit. The storage has a (7) day supply of non-perishable food present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. The kitchen, food storage, and preparation areas are clean.

RECORDS

There is a confidential storage space designated for client and personnel records at the facility.

ADMINISTRATION

The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC613 meets this requirement. Facility Visiting Policy (SAFE HAVEN RESIDENCE HOUSE RULES) is posted. A Licensing Complaint Poster See Something Say Something is posted. There is space available for client council meetings and resident council postings.

ACTIVITIES

There is an outdoor activity space with a table and chairs furnished for outdoor use. There is at least one common room available to clients for visitors.

Component III Power Pointe ARF, presentation and exit interview was conducted with the Administrator Edwin Villanueva and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Troy Watson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4