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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603501
Report Date: 11/10/2021
Date Signed: 11/10/2021 11:42:37 AM

Document Has Been Signed on 11/10/2021 11:42 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:HAVEN'S PLACEFACILITY NUMBER:
198603501
ADMINISTRATOR:WHITE, MICHAELFACILITY TYPE:
735
ADDRESS:592 ARBOLEDA WAYTELEPHONE:
(909) 568-9406
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 4CENSUS: 0DATE:
11/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ApplicantTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a pre-licensing visit. LPA met with Michael White (Applicant). The facility is to serve 4 ambulatory individuals age 18 through 59 years old. Per Applicant, he has not begun the process to become vendored through the Regional Center. Component III was also completed during this visit.

This is a two story home. The first floor consists of a living room, office, dinning room, kitchen, (1) bathroom and laundry room. The second floor consists of (3) bedrooms and (1) bathroom.

The following was observed/inspected:

  • Carbon monoxide detectors and smoke detectors are combined. Tested and operable.
  • Fire extinguishers are located inside the kitchen, laundry and second floor hallway. All extinguishers are new and were purchased on 08/13/2021.
  • Cleaning solutions are locked inside the laundry room.
  • Sharps are locked inside the hallway closet.
  • Building and grounds are free from hazards.
  • Beds have the required linen/supplies.
  • Mattresses and bedsprings are in good repair.
  • Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture.
  • Clients have the appropriate furniture (one chair, night stand, adequate lighting for each client adequate closet and drawer space).

***Refer to LIC 809C for the continuation of this report***
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: HAVEN'S PLACE
FACILITY NUMBER: 198603501
VISIT DATE: 11/10/2021
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  • There are enough bath towels, hand towels and wash cloths for all clients.
  • Sufficient amount of personal hygiene supplies are available for clients. Each client will have their own personal hygiene supply stored inside their hygiene box.
  • PPE supplies are stored inside the laundry room.
  • There are sufficient amount of linens available to permit weekly changing to ensure use of clean linens at all times by clients.
  • Facility has a washer and dryer that are fully operational located inside the laundry room.
  • Pantry's cupboards, freezers, stove, refrigerator and counters are clean.
  • The facility has sufficient dinning tables and chairs.
  • Pesticides and other toxic substances are stored and locked inside the laundry room.
  • Medications to be locked inside the hallway cabinet.
  • Client files will be stored and locked inside the hallway closet.
  • First Aid Kit inspected.
  • Physical plant is in good repair. There is a shaded area to accommodate (6) individuals in the backyard.
  • Building and grounds are free from hazards.
  • Window screens are in good repair and windows/curtains/blinds are in good repair and operate properly.
  • Refrigerator, stove, telephone, sinks, tubs, toilets and showers operate properly.
  • Hot water temperature measured at 113.5*.
  • Personal rights are posted.
  • Emergency Disaster Plan posted.
  • Complaint Procedures posted.
  • LPA also discussed LIC 808/Mitigation Plan with Applicant. Per Applicant, LIC 808/Mitigation Plan was submitted to Centralized Application Bureau (CAB).
  • COVID-19 signage to be emailed to applicant (by LPA Irra).


No deficiencies noted.

Exit interview conducted and a copy of this report was provided to Michael White (Applicant).
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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