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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603501
Report Date: 12/19/2022
Date Signed: 02/06/2023 10:00:27 AM

Document Has Been Signed on 02/06/2023 10:00 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
GREATER LA AC/SC, 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:
12/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michael WhiteTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Michael White and discussed the purpose of today's visit.

The facility is to serve 4 ambulatory individuals age 18 through 59 years old. Per Mr. White, he currently working on becoming vendored through the Regional Center. There are (0) clients residing at this facility.

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 were observed/inspected: .

  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility. Signs to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed (gowns, masks, hand sanitizer, face shields and gloves).
  • Non-perishable foods for 7 days observed. Perishable supply will be added prior to admitting the first client.
  • Medications were not reviewed as there are no clients residing at this facility.
  • Per Mr. White, facility will implement the mitigation plan and infection control procedures prior to the first client admission into this facility.

Exit interview conducted, a copy of this report and Appeal Rights were provided to Michael White.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2022
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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