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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603496
Report Date: 06/01/2023
Date Signed: 06/01/2023 10:12:54 AM

Document Has Been Signed on 06/01/2023 10:12 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 RESIDENTIALFACILITY NUMBER:
198603496
ADMINISTRATOR:JONES, BRITTANYFACILITY TYPE:
735
ADDRESS:980 LOOKING GLASS DRTELEPHONE:
(310) 977-6212
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 4CENSUS: 4DATE:
06/01/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator / Brittany JonesTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a collateral visit to this facility. Upon arriving at the facility, LPA met with Administrator / Brittany Jones who assisted with the visit. LPA explained the purpose for today's Collateral Case Management visit is to interview Client 1 (C1) regarding allegations unrelated to Safe Haven Adult Residential.

An exit interview was conducted and a copy of this report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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