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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 11/09/2023
Date Signed: 11/09/2023 11:50:36 AM

Document Has Been Signed on 11/09/2023 11:50 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:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Maria Caballes- Licensee/AdministratorTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Licensee/Administrator, 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 admitted to the facility. Licensee is still working with San Gabriel/Pomona Regional Center to obtain clients. The facility is a one-story home, operating as an Adult Residential Facility, licensed to serve (4) ambulatory adults, ages 18-59, of which all may be ambulatory, only.

During today's visit, LPA conducted a tour of the physical plant with the Licensee/Administrator. The home is located in a residential area and consists of (3) client bedrooms, (2) bathrooms, a living room, dining room, kitchen, den, attached garage, and shaded patio in the backyard. There is one central entry point for universal entry screening. LPA inspected all client bedrooms and were observed to have the required furniture, storage space, and lighting. All bathrooms were equipped with a toilet, shower, and wash basin. The hot water was tested and measured at 115*F, which is in compliance. The kitchen had the required appliances and 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 food supplies was observed and met the Title 22 Regulation requirements. The smoke/carbon monoxide detectors were tested and were operational at the time of the visit. Fire extinguishers were observed throughout the premises to be fully charged and had current inspections. The Licensee/Administrator's file was reviewed and observed to be complete. An interview was also conducted with the Licensee/Administrator. Due to no clients or staff, no other files and/or medications were reviewed.

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: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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