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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 08/20/2021
Date Signed: 08/20/2021 09:01:02 AM

Document Has Been Signed on 08/20/2021 09:01 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAVEN HOME CARE LLCFACILITY NUMBER:
198603029
ADMINISTRATOR:CABALLES, MARIA JFACILITY TYPE:
735
ADDRESS:935 HEATHER STTELEPHONE:
(626) 215-8680
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 0DATE:
08/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Maria Caballes, administratorTIME COMPLETED:
09:10 AM
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Licensing Program Analyst (LPA) Vasallo conducted a Case Management visit. Administrator requested to decrease the capacity from 6 clients to 4 clients. The new fire clearance for the decrease was granted on 7/28/21. The purpose of today's visit is to confirm the facility only has 4 beds. Bedroom #1 has 1 bed, bedroom #2 has 1 bed and bedroom #3 has 2 beds. The facility currently has no clients living in the facility. The capacity decrease from 6 to 4 will be granted.

Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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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