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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530037
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:31:25 AM

Document Has Been Signed on 10/06/2022 11:31 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NEW HAVENFACILITY NUMBER:
365530037
ADMINISTRATOR:JOSE, JOSEPHFACILITY TYPE:
735
ADDRESS:13019 LEAWOOD STREETTELEPHONE:
(818) 274-1809
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 4CENSUS: 4DATE:
10/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Oyewole Joseph Jose, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. An initial application to operate an Adult Residential Facility was submitted to the Central Applications Unit (CAU) on 6/12/2022 for a total capacity of 4 ambulatory residents. Fire Clearance was granted 06/29/2022 LPA, Allen observed the following:

Structure: Facility was a two story house with a total of five(5) bedrooms and 3.5 bathrooms. There are three (3) resident bedrooms and one (1) staff bedroom, office area, and loft upstairs. There is one (1) bedroom downstairs, a living room, dining, and kitchen area. The home has central heating and air conditioning systems.

Bedrooms: Each resident bedroom will accommodate ambulatory clients only. All bedrooms were adequately furnished with bed, chair, closets, appropriate linens, and adequate lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured at 105.6 F in the main bathroom downstairs in the common area.

Kitchen: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. The knives/sharp instruments were secured in a locked cabinet by the refrigerator. There was adequate room for food storage. The refrigerator/freezer were in working condition . There was a 7-day supply of nonperishable food and 5-day supply of perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.

Linens and Hygiene Supplies: An adequate supply of linens are available.

Yards/Outside: There is a covered patio area for staff and client use. There were no bodies of water observed anywhere on the property.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 365530037
VISIT DATE: 10/06/2022
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Garage: Garage was organized and free of obstructions.

Laundry Area: The laundry area has a washer and dryer and laundry detergents and cleaning solutions were securely locked in a cabinet.

Emergency phone numbers and Exit Plan: Let-Us-No poster, and client’s rights were posted.

General items: The facility has working smoke/carbon monoxide detectors which were tested and operational there were also charge fire extinguishers.

LPA reviewed COMPONENT III with the applicant during this Pre-Licensing Inspection This facility physical plant is prepared for licensure at this time.

An exit interview was conducted, and a copy of this report was given to the administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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