198603029-11-21-2025-28-AS-BGOZ-DNN3HJ-20251121171601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603029
Report Date: 11/21/2025
Date Signed: 11/21/2025 05:16:11 PM

Document Has Been Signed on 11/21/2025 05:16 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 LLC		FACILITY NUMBER:	198603029
ADMINISTRATOR/ DIRECTOR:	CABALLES, MARIA J		FACILITY TYPE:	735
ADDRESS:	935 HEATHER ST		TELEPHONE:	(626) 215-8680
CITY:	GLENDORA	STATE: CA	ZIP CODE:	91740
CAPACITY: 4		CENSUS: 4	DATE:	11/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:31 PM
MET WITH:	Maria Caballez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and the purpose of the visit was explained. Administrator Maria “Joy” Caballes arrived shortly after to assist with the inspection. The facility is licensed to serve clients ages 18-59, approved for four (4) ambulatory only. Licensee works with San Gabriel/Pomona Regional Center to obtain clients. The facility is a single-story home located in a residential area of Glendora. The home consists of three (3) bedrooms, two (2) bathrooms, kitchen, dining area, den, attached garage with laundry, front and back yards. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Combination smoke and carbon monoxide detectors are interconnected, were tested and are operable. Two fire extinguishers observed; one in the garage, another in the kitchen. The facility was observed to be clean, safe, sanitary and in good repair, free of flies and other insects. Outdoor and indoor passageways, open porches and other areas of potential hazard observed to be clean and free of obstruction. No pools or large bodies of water. continued on LIC809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 11/21/2025 05:16 PM - It Cannot Be Edited

Created By: Blanca Gonzalez On 11/21/2025 at 04:33 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: HAVEN HOME CARE LLC	FACILITY NUMBER: 198603029
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.4(g)

Acceptance and Retention Limitations. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients.... the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 4 clients in care are over the age of 59 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2025
	Plan of Correction
1 2 3 4	Licensee agrees to submit to CCL request for age exception documentaion by POC due. Licensee agrees to request documents from regional center regarding placement and submit to LPA as proof.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:

	Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 LLC	FACILITY NUMBER: 198603029
	VISIT DATE: 11/21/2025

NARRATIVE

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continued LIC809

Living room and dining area were observed clean and free of obstruction with sufficient seating. Games and activities were observed stored in living room.
Kitchen was observed clean and free of pests. LPA observed sufficient supply of nonperishable food for one week and perishable foods for a minimum of two days. Soaps, detergents, and cleaning supplies were observed to be stored away from food supplies. Disinfectants, cleaning solutions, and other items that could pose a danger if readily available to clients were observed to be stored where inaccessible to clients locked under the kitchen sink. Temperature at facility was comfortable set at 68°F. Water temperature tested in hall bath, measured 109.7°F and in private bath at 111.3° which is within the required 105° F - 120° F.
LPA inspected all client bedrooms and contained required bedroom furniture including, for each client, a bed, a chair, a night stand, and a lamp or lights sufficient for reading. Linens were observed clean and in good repair. Extra linens observed in hall closet.
Laundry area for client use and necessary supplies are available. Washer and dryer were operable at time of visit.
Centrally stored medications were observed secured in a locked cabinet located in the kitchen. The facility uses the Medication Administration Record (MAR) log to document medications given.
Four (4) resident and three (3) staff files were reviewed and were observed to contain required documentation. 2 out 4 residents are over the age of 59, deficiency cited.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report along with appeal rights were provided to the Administrator Maria Caballes.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025

LIC809 (FAS) - (06/04)

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