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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:58:18 PM

Document Has Been Signed on 01/16/2025 02:58 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: 4DATE:
01/16/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Raymund Caballes, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Daniel Konishi made an unannounced case management visit regarding a self-reported incident on the relocation of 4 clients from Bedell Family Circle - License # 191200023, 962 East Concha St., Altadena, CA 91001 to Haven Home Care LLC-License # 198603029 due to mandatory evacuation orders from Fire Advisory. LPA met with S1 and explained the purpose of the visit. During the visit, LPA Konishi spoke with the Administrator, Maria Caballes over the phone and explained the purpose of the visit.

During the visit today, LPA Daniel Konishi conducted a health and safety check, and no concerns were observed. LPA obtained a copy of the staff schedule but did not obtain a copy of the staff and client roster. Administrator will send the copy of the staff and client roster to the LPA Konishi. The last disaster/fire drill was not conducted because facility was un-occupied. Administrator will promptly schedule and conduct a disaster/fire drill now that there are clients in placement.

Per interview with the administrator over the phone, there are 4 clients that have been relocated from Bedell Family Circle. They have sufficient staffing to meet the needs of the clients. Food and hygiene supplies are available to accommodate a total of 4 clients. The facility has 3 bedrooms, 2 bathrooms, living room, dining area, staff office area, and kitchen. The medications and MAR logs for the 4 individuals from Bedell Family Circle were transferred to the facility and are centrally stored and locked. All the clients in the facility are ambulatory and do not use any assisted devices. All clients in the facility do not require incontinence services. Administrator stated the families, responsible parties, and regional center for Bedell Family Circle clients have been notified about the relocation either via calls, texts, or emails.

An exit interview was held and a copy of this report was given to S1.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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