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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603048
Report Date: 06/12/2025
Date Signed: 06/12/2025 12:11:53 PM

Document Has Been Signed on 06/12/2025 12:11 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:SAFE HAVENFACILITY NUMBER:
198603048
ADMINISTRATOR/
DIRECTOR:		CARYL LARKFACILITY TYPE:
772
ADDRESS:12580 LAKELAND AVETELEPHONE:
(562) 906-2686
CITY:SANTA FE SPRINGSSTATE: CAZIP CODE:
90670
CAPACITY: 16CENSUS: 8DATE:
06/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Maria Ortiz Social WorkerTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA’s) Christian Gutierrez and Sakinah Madyun conducted an unannounced annual visit at the facility using the CARE Tool. LPA’s met with Maria Ortiz Psychiatric Social Worker and explained the reason for the visit. Administrator Cary Lark arrived shortly. The facility is a Social Rehabilitation Facility licensed to serve 16 ambulatory only clients. This facility is considered a short-term crisis residential treatment program.

A tour of the single-story building included: reception area, 2 group rooms, waiting room, 5 offices, 8 client bedrooms, 3 client bathrooms,1 staff bathroom, 1 medication room, kitchen, dining room, outside patio, and outside storage shed. LPA’s toured the facility and the following was observed: a total of 8 clients were at the facility during the visit. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked inside a staff bathroom. There are multiple fire extinguishers throughout the facility. All the fire extinguishers are fully charged. Facility has a sprinkler fire system throughout the facility. There are carbon monoxides in each bedroom and throughout the facility. LPA’s toured random bedrooms, and each have the required bedding and furniture. One bedroom was observed to have dirty sheets and pillowcase. The bathrooms were observed to be clean, and shower has a non-skid mat. The water temperature was tested in bathrooms and are within the required 105-120 degrees F. The program maintains a comfortable temperature in each room. The First Aid kit is kept in the front office, and it is fully stocked with all required items including a current manual. Sufficient food supplies for at least 2 days of perishables were observed. LPA’s did not see a sufficient amount of 7 days non-perishables food. Sharps are kept locked in drawer in kitchen. The last fire drill/earthquake drill was conducted in April of 2025. LPA's reviewed medication for 3 clients and observed that medications are documented properly and given as prescribed. LPA's reviewed 4 client and 4 staff records. Two staff and three clients were interviewed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christian Gutierrez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
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 06/12/2025 12:11 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/12/2025 at 11:53 AM
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: SAFE HAVEN
FACILITY NUMBER: 198603048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81076(d)(1)
Food Service
(d) The licensee shall meet the following storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above facility did not maintain a supply of 7 day nonperishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Staff agrees to purchase a supply of 7 day nonperishable food and send LPA a receipt by email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2025 12:11 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 06/12/2025 at 11:53 AM
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: SAFE HAVEN
FACILITY NUMBER: 198603048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(i)(4)
Fixtures, Furniture, Equipment, and Supplies
(i) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels, and washcloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation), the licensee did not comply with the section cited above in one (1) of bedrooms had dirty sheets and pillow case which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2025
Plan of Correction
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Staff agrees to change dirty linen and send picture to LPA by POC due date. Staff will also insure clients have access to clean linen at all times.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Christian Gutierrez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
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