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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603496
Report Date: 11/07/2022
Date Signed: 12/22/2022 04:48:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/22/2022 04:48 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:SAFE HAVEN ADULT RESIDENTIALFACILITY NUMBER:
198603496
ADMINISTRATOR:JONES, BRITTANYFACILITY TYPE:
735
ADDRESS:980 LOOKING GLASS DRTELEPHONE:
(310) 977-6212
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 0DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrator, Brittany JonesTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Annual Required / Infection Control visit to the above facility. Upon arriving at the facility, LPA knocked on the door but there was no answer. LPA called the Administrator, Brittany Jones to explain the purpose of the visit. Administrator stated she will meet LPA at the facility in 1/2 hour. At 1:26pm, Administrator called back to ask LPA to wait longer due to a scheduling conflict. Administrator arrived at 2:10pm and LPA was let in. Administrator conducted covid 19 screening and asked LPA to sign in. This facility serves clients age range 18 through 59 and approved for four (4) ambulatory. It is serviced by San Gabriel/Pomona Regional Center. Currently, there are zero (0) clients due to the unexpected enacted moratorium that SGPRC has in place. Administrator is up to date with annual fees. Administrator was also reminded to submit the Infection Control Plan for the facility. At 2:30pm, back-up Administrator Oghenetega Ugbeyide arrived and assisted with the inspection.

LPA and Administrator inspected the entire facility inside and out. The facility is a conventional single-story home located in a residential neighborhood. Home consists of (4) bedrooms, (2) full bathrooms, living room, family room/office, dining area, breakfast nook, kitchen, laundry located inside the home, 2-car attached garage and backyard. COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms’, bathrooms, and hallways. Both Administrators were wearing their face masks during the visit. Facility has an adequate amount of PPEs stored in a locked cabinet inside the home.

At 2:15pm, LPA and Administrator Jones toured the kitchen. Freezers/refrigerators appear sanitary and temperature maintained. There was sufficient supply of perishable for 2 days & non-perishable foods for 7 days. The hot water in the kitchen was tested and read at 117.7 deg F which is within the Title 22 regulations. LPA also observed that knives and other sharp items locked in the kitchen cabinet and inaccessible to clients. There were two (2) fire extinguishers, one located next to the breakfast nook and the other one was mounted by the door in the garage. Both fire extinguishers are new and last inspected on Sep. 1, 2022.

******REPORT CONTINUED ON LIC 809-C******
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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
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: SAFE HAVEN ADULT RESIDENTIAL
FACILITY NUMBER: 198603496
VISIT DATE: 11/07/2022
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All four (4) clients’ rooms were checked and have the required items like bed, linens, night stand, lighting, trash can, chest drawers, chair and closet which were all in good condition at the time of the visit. LPA observed that all bedrooms were well-lit and had sufficient closet/ storage space. Bathrooms were clean and operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries were accessible to clients. Hot water temperature properly measured at 115.5 deg F in bathroom #1 and bathroom #2 hot water temperature read at 109.8 deg F. Cleaning agents, laundry soaps and other hazardous materials are all stored in a locked cabinet inside the garage. There are (2) fireplaces in the home that are both secured and locked. There are no cameras observed in the home.

LPA observed that smoke detectors and carbon monoxide detectors were operational. No firearms were stored at the facility and no bodies of water present. There were no medications stored yet but it will be stored in the upper cabinet in the kitchen area. The medications will be locked and inaccessible to clients. First aid kit was inspected and observed to be fully stocked with manual and in compliance with Title 22 Regulations

At 2:35pm, LPA toured the backyard along with the back-up Administrator Ugbeyide and observed the side and backyard areas to be clean and free of debris. LPA observed a shaded area with chairs provided for clients and visitors in the backyard area. LPA observed the facility to be clean and appropriately furnished with clear passageways inside.

The Facility Administrator Certificate for Brittany A. Jones expires on 8/01/2024 and Administrator Certificate for Oghenetega Ugbeyide expires on 07/23/2024.

No deficiencies cited, exit interview conducted and a copy of this report were provided to the Administrator, Brittany A. Jones.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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