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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603322
Report Date: 09/30/2024
Date Signed: 09/30/2024 08:58:24 AM

Document Has Been Signed on 09/30/2024 08:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAVEN HOUSE RESIDENTIAL FACILITIES INCFACILITY NUMBER:
198603322
ADMINISTRATOR/
DIRECTOR:		CAGE, WANDAFACILITY TYPE:
735
ADDRESS:757 EDWIN AVETELEPHONE:
(909) 436-7423
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 2DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:John Alfred/S-1TIME VISIT/
INSPECTION COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted the required annual inspection. LPA met with John Alfred/S-1 and discussed the purpose of today’s visit.

This home consists of (3) bedrooms, (1) office, (2) bathrooms, kitchen with dining area, living room and an attached garage. San Gabriel Pomona Regional Center provides case management services for all clients residing at this facility.

LPA utilized the Compliance and Regulatory (CARE) tools for the visit today and observed the following:
Infection Control: Facility has an Infection Control and Prevention Plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector (located in the hallway) tested and operable. Fire extinguisher located in the kitchen and appeared to be full. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Administrator and Staff #1 (S-1) through Staff #3 (S-3). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis.

**Refer to LIC 809C for the continuation of this report**
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAVEN HOUSE RESIDENTIAL FACILITIES INC
FACILITY NUMBER: 198603322
VISIT DATE: 09/30/2024
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Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) and Client #2 (C-2). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent For Medical Treatment, House Rules, Individual Program Plan, and Client Rights were observed.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and locked. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per S-1, there are (0) clients with a restrictive health plan, (0) clients utilizing postural supports and (0) clients with prohibited health conditions

Disaster Preparedness: The facility has an Emergency Disaster Plan in place.

Exit interview, appeals rights and a copy of this report was provided to John Alfred/S-1.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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