<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603048
Report Date: 06/02/2026
Date Signed: 06/02/2026 12:57:29 PM

Document Has Been Signed on 06/02/2026 12:57 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: 14DATE:
06/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:56 AM
MET WITH:Maria Ortiz-Clinical ManagerTIME VISIT/
INSPECTION COMPLETED:
01:00 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 Analysts (LPA) Elena Mallett arrived at the facility to conduct an unannounced Annual visit . LPA met with Clinical Manager Maria Ortiz and the purpose of the visit was explained. Program Director Caryl Lark was notified by telephone and joined the visit shortly after. The facility is a short-term Residential Treatment Program that can serve 16 ambulatory adults.

The facility is located in a business park in Santa Fe Springs. The facility consists of a eight (8) shared client rooms, dining area, a kitchen, (3) client bathrooms, (1) staff bathroom, meeting rooms and staff offices, nurse office and an outdoor patio area with shaded seating and a basketball court.

LPA completed the visit using Compliance and Regulatory Enforcement Tools (CARE) . The following domains were completed during the visit

Infection Control: Infection Control Plan was reviewed by LPA. Facility follows title 22 regulations and is cleaning and disinfecting regularly. Staff has PPE and practices hand hygiene.

Physical Plant and Environmental Safety: Physical plant is clean and sanitary and the hallways and walkways are free from debris and obstruction. Hot water temperature did not measure within Title 22 regulations any of the 3 client bathrooms. A deficiency was cited. See 809-D. Facility has smoke and carbon monoxide detectors that were tested and operational. 4 fully charged fire extinguishers were observed. Sharps and toxins and cleaners are locked in cabinets. Client bedrooms had required light and furnishings. Extra linens and blankets and towels were observed.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
Document Has Been Signed on 06/02/2026 12:57 PM - It Cannot Be Edited


Created By: Elena Mallett On 06/02/2026 at 12:11 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: SAFE HAVEN
FACILITY NUMBER: 198603048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in 3 out of 4 bathroom sinks did not deliver hot water within Title 22 requirments of 105-120F( Bathroom1 - 123.2 F, Bathroom 2-122 F and Bathroom 3- 122 F) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2026
Plan of Correction
1
2
3
4
BY POC due date Administrator will fax to Licensing a water log showing the hot water tempertures in Bathroom 1, 2 and 3 to be measure within Title 22 requirments of 105-120F. Administrator will also send a log of tempertures in Bathroom 1,2 and 3 for 3 consecutive days with tempertures measured at three different times a day that show the water in the sinks of Bathrooms 1, 2 and 3 is measuring within TItle 22 requirments of (105-120F)
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.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Elena Mallett
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SAFE HAVEN
FACILITY NUMBER: 198603048
VISIT DATE: 06/02/2026
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
26
27
28
29
30
31
32
Operational Requirements: Fire clearance approval was observed. Plan of operation was observed. Outdoor activity space with a furnished, shaded area was present. Activity supplies for clients were observed. A monthly activity calendar was provided. Clients attend group program, go on walks and participate in Bingo, karoke and sports at the facility. Books, games and television are available for clients. Staff monitors clients every hour by in-person bedroom checks and cameras in the common areas.

Personal Records - Training: Locked storage space for staff files was observed. 5 staff files were reviewed for Criminal Background Clearance, First Aid training, initial and ongoing training and health screening. No issues were observed.

Client Records - Incident Reports: Locked Storage space for client files was observed. Clients’ files were reviewed for Emergency Face sheet, Physician’s Report with ambulatory status, Needs and Services plan, Admission Agreement and Personal Rights. Five client were reviewed and no issues were observed.

Client Rights - Information: Required postings were observed.

Food Service: Kitchen had functional appliances and was equipped to store and prepare food. However, meals are prepared at near by facility and brought to Safe Haven at meal times. Snacks are stored on site. 2 day perishable and 7 day non perishable food supply was observed at the near by facility. Food was kept separate from cleaners, toxins and poisons. Emergency food and water was present at Safe Haven facility.

Health Related Services:2 complete First Aid Kits were observed and a manual was present. Facility utilizes a Medical Record Log. Three clients medicine logs were reviewed with no issues.

Disaster Preparedness: Facility has emergency disaster plan in place. Administrator will send updated Disaster Plan form to Licensing. Facility conducts quarterly disaster drills. The last drill was conducted on 05/31/26. Facility had several flashlights and emergency supply of water and food.

Program Director Caryl Lark had to leave before the visit was completed. An exit interview was conducted with Clinical Manager Maria Ortiz. A deficiency was cited today Per 22 Regulations. A copy of this licensing report and Appeal Rights were provided to Clinical Manager Maria Ortiz..

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Elena Mallett
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4