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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603322
Report Date: 08/26/2020
Date Signed: 09/10/2020 09:05:26 AM

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: 0DATE:
08/26/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Lindon Johnson (Applicant) and Wanda Cage (Administrator)TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically/tele-visit with Applicant) Lindon Johnson. Participants in this tele-visit: Mr. Johnson, Wanda Cage (Administrator), Daniel Chavez (CCLD) and Elizabeth Irra (CCLD-LPA). The facility is to serve 4 ambulatory Developmentally Disabled individuals age 18 through 59 years old.

This is a single story home with 3 bedrooms, 1 office, 2 bathroom kitchen with dinning area, living room and an attached garage.

The following was observed/inspected:
  • Smoke detectors operate properly.
  • Carbon monoxide detector was tested and operable.
  • Fire extinguisher located in the kitchen and is properly charged. **Purchase receipt to be added onto it**
  • Cleaning solutions and sharps are locked.
  • Building and grounds are free from hazards.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.
  • Clients have the appropriate furniture (one chair, night stand, adequate lighting for each client adequate closet and drawer space).
  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Sufficient amount of personal hygiene supplies are available for clients. They all have their own hygiene basket.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by clients.
***Refer to LIC 809C for the continuation of this report***
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 INC
FACILITY NUMBER: 198603322
VISIT DATE: 08/26/2020
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  • Facility has a washer and dryer that are fully operational located inside the garage.
  • Pantry's cupboards, freezers, stoves, microwaves, refrigerator and counters are clean.
  • Two day supply of perishables available, seven day supply of non-perishable available.
  • The facility has sufficient dinning tables and chairs.
  • Pesticides and other toxic substances are stored and locked away from food supply.
  • There is a designated space for Medications to be locked. (Inside a locked kitchen cabinet)
  • Resident records (including cash resources) are inaccessible to unauthorized persons. They will be stored inside a locked filling cabinet near the living room.
  • Physical plant is in good repair.
  • Building and grounds are free from hazards.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. **Licensee will be changing both full-size beds in room #2 and will be adding twin size beds instead to provide more space**
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Personal rights are posted.

The following items will be corrected by Applicant no later than 09/02/20 and Applicant will submit proof of correction to LPA:
  • Bedroom #2: Licensee will be changing both full-size beds and will be adding twin size beds instead to provide more space.
  • First Aid Kit - needs a thermometer and a first aid manual (American Heart Association).
  • Water: Measure hot water temperature supply for both bathrooms and kitchen.
  • Kitchen: Purchase utensils to accommodate (4) clients.
  • Outdoors: Shaded area set up in the backyard to accommodate (4) clients.
  • Postings: Emergency disaster plan and complaint procedures to be posted.
  • Fire Place to be safeguarded (although it is non-operational).


Exit interview conducted, copy of report provided to Mr. Johnson (Applicant) electronically for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020
LIC809 (FAS) - (06/04)
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