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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603496
Report Date: 10/03/2023
Date Signed: 10/03/2023 04:09:23 PM

Document Has Been Signed on 10/03/2023 04:09 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: 4DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Brittany Jones, AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA arrived unannounced and met with Administrator, Brittany Jones. The purpose of the visit was explained. The facility is licensed for (4) ambulatory adults, ages 18 - 59 and is vendorized by the San Gabriel/Pomona Regional Center.

LPA toured the facility and conducted the following domains during the visit today:
Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves when necessary. Staff are continuing to clean and disinfect the facility daily. Facility has submitted the Infection Control Plan.
Physical Plant & Environment Safety: The facility does not have any swimming pool or bodies of water on the premises. There are 4 client bedrooms, 1 staff room in the garage, 2 bathrooms, living room, dining area, kitchen, family room/office, laundry room, and attached garage. Each client bedroom has the required furniture and bedding. Extra hygiene supplies and linens are observed. Knives, cleaning solutions, and disinfectants are locked. There are no firearms or weapons stored at the facility.
Operational Requirements: The facility is operating within the approved fire clearance. There are 4 ambulatory clients residing at the home. Staff are providing the care and supervision as necessary to meet the clients' needs.
Food Service: There are sufficient food supplies of 2 day perishable and a week of non-perishable. The kitchen is clean and free of pests.
Disaster Preparedness: The facility has the updated Emergency Disaster Plan with emergency procedures noted.

No deficiencies issued today. LPA will return on a later date to complete the remainder of the domains. An exit interview was conducted and a copy of this report was given to Administrator Jones.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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