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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603496
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:50:52 PM

Document Has Been Signed on 10/05/2023 03:50 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:
10/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:Brittany Jones, AdministratorTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to complete the annual inspection. LPA arrived unannounced and met with Administrator, Brittany Jones. The purpose of the visit was explained.

LPA continue the inspection using the CARE tools:
Staffing: There is sufficient staffing at the facility. Administrator Certificate for Brittany Jones expires on 8/1/24. The HIV and TB Training was completed on 4/22/22. Staff employed are fingerprint cleared and associated to the facility.
Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 3 staff files. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis result on file. Staff are receiving on-going training.
Client Rights-Information: Client rights are posted and included in Client files. There are no clients using postural supports.
Client Records-Incident Reports: LPA reviewed all 4 Client files. Client files are organized and include the following documents: Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent For Medical Treatment, Individual Program Plan/IPP, Client Rights, Inventory form, and P&I ledgers.
Health Related Services: The medications are centrally stored. LPA reviewed medications for 2 Clients who are taking medications. Facility uses the Medication Administration Record (MAR) log to document medications given and are being administered as prescribed by the Physician.
Incidental Medical Services: There are (0) clients with restricted health condition plan.

No deficiencies were issued. An exit interview held. A copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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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