198603322-9-28-2023-28-AS-EIRA-CW4QYD-20230928123458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603322
Report Date: 09/28/2023
Date Signed: 09/28/2023 02:29:23 PM

Document Has Been Signed on 09/28/2023 02:29 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	HAVEN HOUSE RESIDENTIAL FACILITIES INC		FACILITY NUMBER:	198603322
ADMINISTRATOR:	CAGE, WANDA		FACILITY TYPE:	735
ADDRESS:	757 EDWIN AVE		TELEPHONE:	(909) 436-7423
CITY:	POMONA	STATE: CA	ZIP CODE:	91767
CAPACITY:	4	CENSUS: 4	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	John Alfred and Lindon Johnson		TIME COMPLETED:	12:50 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 the required annual inspection. LPA met with John Alfred and discussed the purpose of today’s visit. Lindon Johnson arrived at approximately 10:10 A.M. and assisted with this visit. This home consists of 3 bedrooms, 1 office, 2 bathrooms, kitchen with dining area, living room and an attached garage. This facility is licensed for (4) ambulatory clients. San Gabriel Pomona Regional Center provides case management services for all (4) clients residing at this facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: Last Disaster Drill was conducted in August 2023. Staff are adhering to operational requirements. Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detector were tested and are operable. Fire extinguisher observed in the kitchen and appeared to be full. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Water temperature measured as follows: 105.8. Staffing*: There is sufficient staffing at the facility. Administrator Certificate on file for Wanda Cage expires on 01/11/25. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Refer to LIC 809C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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: 09/28/2023

NARRATIVE

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Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff # 4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Wanda Cage (Administrator) last HIV and TB training certificate is dated 09/22/2022.

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) through Client #4 (C-4). Client files are maintained at the facility. C-1 is missing the Admission Agreement and Physician’s Report with TB results and Ambulatory Statement. Deficiencies cited.

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. Pesticides and cleaning supplies are kept away from the food preparation areas. 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 inside a locked cabinet near the kitchen and dining area. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician.

Incidental Medical Services: There are no clients with a restricted health condition plan in place.

Disaster Preparedness: The facility does not have an Emergency Disaster Plan (LIC610D/9 pages) in place. Deficiency cited.

Deficiencies cited under Title 22. Exit interview, appeals rights and a copy of this report was provided to Lindon Johnson.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 02:29 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in (1) out of (4) client files which poses/posed a potential health, safety or personal rights risk to persons in care. C-1 is missing an admission agreement (C-1's admission date: 07/03/23).
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Facility Administrator to provide a copy of C-1's Admission Agreement to LPA Irra by POC due date.

Type B

Section Cited

CCR

80069(c)

Client Medical Assessments

(c) The medical assessment shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in (1) out of (4) client files which poses/posed a potential health, safety or personal rights risk to persons in care. C-1 is missing an annual physical/physician's report with T.B. results and Ambulatory Statement.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Facility Administrator to provide a copy of C-1's annual physical/physician's report with T.B. results and Ambulatory Statement to LPA Irra by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/28/2023 02:29 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(a)

Other Provisions

(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the facility did not have a complete disaster and mass casualty plan which poses/posed a potential health, safety or personal rights risk to persons in care. This standard is not met at evidence by: Facility does not have a complete Disaster and Mass Casualty Plan (LIC 610/9 page document).
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Administrator to complete and submit the emergency and disaster plan to LPA Irra by POC due date noted above

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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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