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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:02:29 PM

Document Has Been Signed on 10/03/2024 01:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAVEN HOME CARE LLCFACILITY NUMBER:
198603029
ADMINISTRATOR/
DIRECTOR:		CABALLES, MARIA JFACILITY TYPE:
735
ADDRESS:935 HEATHER STTELEPHONE:
(626) 215-8680
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 0DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Christine Caballes, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) S. Vaid made an unannounced visit to the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) tool in facility evaluation. LPA met with Co-Administrator, Christine Caballes and explained the purpose for the visit. Licensee/Administrator was not available for tour during the time of the visit.
The license became effective 11/8/2019, currently there are no clients residing in the home. 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 Co-Administrator Christine Caballes. The home is located in a residential area and consists of three (3) client bedrooms, two (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 106.4-110.3, for 2 bathrooms and kitchen taps and are 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. The food supplies were observed and met the Title 22 Regulation requirements. The smoke/carbon monoxide detectors are interconnected were tested and are operational at the time of this visit. Fire extinguishers were observed throughout the premises to be fully charged and had current inspections dated 12/12/ 2023. The Licensee/Administrator's file was reviewed and observed to be complete. An interview was also conducted with the Co-Administrator. Due to no clients or staff, no other files and/or medications were reviewed. Licensee/Administrator’s certification expires 11/07/2025.
Per Title 22 Regulations, there were no deficiencies observed during the visit.
An exit interview was conducted with Co-Administrator, Christine Caballes, and a copy of the report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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