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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603322
Report Date: 11/14/2024
Date Signed: 11/14/2024 10:30:25 AM

Document Has Been Signed on 11/14/2024 10:30 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:
11/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:John AlfredTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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 a Case Management visit to issue a citation. LPA met with John Alfred and discussed the purpose of today’s visit.

During this visit, LPA obtained a copy of the staff and client rosters. LPA addressed an incident which occurred on 04/23/24 involving C-1 and C-2. C-1 no longer resides at this facility (moved out 04/25/24). During an investigation regarding C-1 and C-2, Investigator Laura Garcia (CCLD-Investigation Branch) obtained a copy of the Corrective Action Plan (CAP) from San Gabriel Pomona Regional Center that was issued to this facility due to staff failing to provide immediate medical attention to C-1. Per CAP, on 04/23/24, C-1 and C-2 were involved in a physical altercation in which injuries were sustained and facility staff failed to provide immediate medical care. Per CAP, C-1 was taken to hospital Emergency Room the following day (04/24/24) in which C-1 was diagnosed with a nasal fracture and fractured right eye bone.

Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.



Exit interview conducted, appeal rights and this report was provided to John Alfred.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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 2
Document Has Been Signed on 11/14/2024 10:30 AM - It Cannot Be Edited


Created By: Elizabeth Irra On 11/14/2024 at 09:55 AM
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: HAVEN HOUSE RESIDENTIAL FACILITIES INC
FACILITY NUMBER: 198603322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
80065(a)

1
2
3
4
5
6
7
Personnel Requirement (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.This standard is not met at evidence by: On 04/23/24, C-1 and C-2 were involved in a physical
1
2
3
4
5
6
7
Administrator to provide staff training and discuss the importance of meeting individual clients needs (specifically how to address client injuries in a timely manner) and submit proof of training to LPA Irra by POC due date.
8
9
10
11
12
13
14
altercation in which injuries were sustained and facility staff failed to provide immediate medical care. C-1 was taken to hospital Emergency Room the following day (04/24/24) in which C-1 was diagnosed with a nasal fracture and fractured right eye bone.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2