198603496-9-27-2021-28-AS-LJNS-C79PJ4-20210927112055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603496
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:21:13 AM

Document Has Been Signed on 09/27/2021 11:21 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SAFE HAVEN ADULT RESIDENTIAL		FACILITY NUMBER:	198603496
ADMINISTRATOR:	JONES, BRITTANY		FACILITY TYPE:	735
ADDRESS:	980 LOOKING GLASS DR		TELEPHONE:	(310) 977-6212
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY: 4		CENSUS: 0	DATE:	09/27/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Brittany Jones		TIME COMPLETED:	11:30 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 Analysts (LPAs) Nicole Spencer initiated an announced pre-licensing inspection and COMP III orientation. Administrator Brittany Jones was present during the Pre-Licensing evaluation and LPA explained the purpose of the visit. An application was submitted to Community Care Licensing Department (CCLD) for an initial application of an Adult Residential Facility (ARF) to serve adults ages 18 to 59. The requested capacity is for four (4) ambulatory residents. Structure: Facility is a single story home consisting of four (4) client bedrooms, an office, two (2) bathrooms, a kitchen, dining area, and living room. The home has a front yard and visitation area, backyard, attached garage, and laundry room with washer and dryer. The front yard is landscaped with grass and has an entrance gate leading to the front entrance. There is also a side gate leading to the backyard. Bedroom Clients: Each client will have their own bedroom. Each bedroom contained a bed, dresser, night stand, chair, and lighting. Bathrooms: Each bathroom has a working toilet, wash basin, and bathtub or shower. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, flat sheet, and blanket and comforter. An adequate supply of linens are stored in the hallway closets. Clients have individual hygiene supplies stored in the hallway closet which include toothbrush, toothpaste, body wash, lotion, comb and brush. Posters and Signage: Emergency Disaster Plan, Labor Information, Personal Rights, and Complaint procedures were posted and readily available for review. Telephones and Fire Extinguishers: One (1) fully charged fire extinguisher was located in the kitchen area. Facility has a working land line telephone. Food Service: Dishes, cups, flatware, and pots are stored in the kitchen cupboards, inspected and in good repair. Knives and other sharp kitchen utensils were in a locked and inaccessible drawer. There was an adequate supply of non-perishables (7 days) and perishable foods (2 days). A variety of foods were observed. ***See LIC 809C for continuation of report.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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: SAFE HAVEN ADULT RESIDENTIAL	FACILITY NUMBER: 198603496
	VISIT DATE: 09/27/2021

NARRATIVE

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Smoke Detectors: There are six (6) electrical & inter-connected smoke detectors located in the facility. The carbon monoxide detector is operational. Appliances: Stove, microwave, refrigerator, dishwasher and washer/dryer are in working condition. There is a working refrigerator and connected freezer in the kitchen. The residence is equipped with central air and heating throughout the facility. Toxins: Cleaning supplies and toxins were locked and only accessible to staff. Water Temperature: Hot water was tested in all bathrooms and the kitchen sink; water temperature measured within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications will be stored in the kitchen in a locked cabinet. A first-aid kit has been inspected; it contained tweezers, thermometer, scissors, antiseptic, bandages, gauze and updated first aid manual. Clients & Staff Files: Designated area for files will be stored in the locked office. Applicant will handle cash resources of residents and there was designated space to separate cash resources. Bodies of water, Fireplaces & Pets: No bodies of water and no pets on these premises. Two fireplaces were observed that were screened and locked. Fire Clearance: Fire clearance was approved on 8/27/2021 for four ambulatory clients Component III: Component III was conducted.

An exit interview was conducted and a copy of this report has been furnished to the Administrator. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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