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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 02/09/2023
Date Signed: 02/10/2023 08:04:00 AM

Document Has Been Signed on 02/10/2023 08:04 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
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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maria Caballes- LicenseeTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) V. Maldonado made a visit to the facility for the purpose of conducting the required annual inspection. LPA met with Licensee, Maria Caballes and explained the purpose for the visit. The license became effective 11/8/19 and there are currently no clients in the home, nor have there ever been any clients in the facility. Licensee is still working with San Gabriel/Pomona Regional Center to obtain clients.

During today's visit, LPA conducted a tour of the physical plant with the licensee. The facility is a one-story home, located in a residential area. The home consists of 3 client bedrooms, 2 bathrooms, a living room, dining room, a kitchen, and a den used as the central entry point for universal entry screening. LPA observed client bedrooms to have the required furniture such as bedframes, mattresses, dressers and lamps. The bathrooms were observed to be clean and the hot water temperature measured at 109.4*F, which is within Title 22 Regulations. The kitchen has the required appliances and all were operating properly at the time of the visit. The front and backyard are well maintained. There is an above ground jacuzzi in the backyard with a hard cover on top and has no water. Licensee states once clients are admitted, the jacuzzi will be removed. The smoke/carbon monoxide detectors were tested and were operational at the time of the visit. Since there are no clients or staff, there were no files and/or medications to review.

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

An exit interview was conducted with licensee, Maria Caballes and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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