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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:02:20 AM

Document Has Been Signed on 11/02/2021 11:02 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: 4CENSUS: 0DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Ruby Caballes, ManagerTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Vasallo conducted a required annual visit. LPA met with Manager, Ruby Caballes and explained the reason for the visit. There are currently no clients in the home. The license became effective 11/8/19 and there have never been any clients in the facility. Licensee is still working with San Gabriel/Pomona Regional Center to obtain clients.

LPA toured the home with the Manager. The facility has 3 bedrooms and 2 bathrooms. Resident bedrooms have the required furniture such as bedframes, mattresses, dressers and lamps. The bathrooms are clean and the hot water temperature was 118.1 degrees which is within the required 105 - 120 degrees. The kitchen has the required appliances and all were operating at the time of the visit. The front and backyard are well maintained. There is no pool, however there is an above ground jacuzzi in the backyard. The jacuzzi has a hard cover on top and has no water. Since there are no clients or staff, there were no files to review.

Per Title 22 Regulations, there were no deficiencies observed during the visit.

Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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