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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603322
Report Date: 09/15/2021
Date Signed: 09/15/2021 03:19:13 PM

Document Has Been Signed on 09/15/2021 03:19 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAVEN HOUSE RESIDENTIAL FACILITIES INCFACILITY NUMBER:
198603322
ADMINISTRATOR:CAGE, WANDAFACILITY TYPE:
735
ADDRESS:757 EDWIN AVETELEPHONE:
(909) 436-7423
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 3DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:LicenseeTIME COMPLETED:
12:00 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 Analyst (LPA) Elizabeth Irra conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Licensee and explained the purpose of the visit.

This is a single story home with 3 bedrooms, 1 office, 2 bathroom kitchen with dinning area, living room and an attached garage. All clients receive case management services provided by San Gabriel Pomona Regional Center.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this home, in all common rooms and hallways.
  • Social Distancing observed.
  • Three (3) client rooms were inspected.
  • Medications for (3) clients were reviewed.
  • Incontinence supplies observed.
  • Hygiene supplies observed.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • PPE supplies inspected. Additional supply warranted. Advisory note provided.


Exit interview conducted, a copy of this report and Appeal Rights were provided to Licensee.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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 1