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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603501
Report Date: 09/20/2021
Date Signed: 09/20/2021 11:20:55 AM

Document Has Been Signed on 09/20/2021 11:20 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:HAVEN'S PLACEFACILITY NUMBER:
198603501
ADMINISTRATOR:WHITE, MICHAELFACILITY TYPE:
735
ADDRESS:592 ARBOLEDA WAYTELEPHONE:
(909) 568-9406
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: DATE:
09/20/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Michael White-CEO/AdministratorTIME COMPLETED:
10:28 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
COMP II Participant: Michael White, CEO/Administrator
Interview Method: Telephone interview

On 9/20/21, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: Anna Barrios
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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