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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804040
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:45:30 PM

Document Has Been Signed on 03/11/2022 03:45 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HAVEN CARE HOME LLCFACILITY NUMBER:
486804040
ADMINISTRATOR:GBY, ARMELLE MFACILITY TYPE:
735
ADDRESS:151 FORSYTHIA CTTELEPHONE:
(510) 395-3966
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 0DATE:
03/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Armelle GbyTIME COMPLETED:
03:47 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted a pre-licensing inspection on 3/11/2022. This is a single story home, with 4 bedrooms that will be used for clients, 2 bathrooms, living room, dining room, kitchen, two hallway closets and garage.
LPA met with applicant Armelle Gby who will be the Administrator once the facility is approved for licensure. The facility received a fire clearance approval from the Vallejo Fire Department on 1/19/2022 for a total of 5 ambulatory clients. Facility will operate with 24 hour staffing and Licensee will ensure sufficient staffing at all times.

During today’s visit LPA observed the following items:
· Lockable metal cabinet for medication and client files.
· Toxins/cleaners are stored in the locked garage and knives are inaccessible in a high cabinet or will be locked in a drawer.
· All exits were unobstructed.
· 5 smoke detectors combination smoke & carbon monoxide detector, which were tested and observed operational and fire pull alarm.
· Complete first Aid kit, night-lights, and flashlights for emergency lighting.
· Supply of linens, paper products, and hygiene supplies available
· Fire Extinguisher charged and serviced 11/25/2021
· Required furnishings in all 4 bedrooms that include, bed, night stand, lamp, chair, dresser and required linens.
· Administrator Certifications; Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, and visitor policy).
· The water temperature was tested during inspection and was within regulation of 105-120 Degrees F.

The Component III Orientation was completed with applicant Armelle Gby.

LPA will submit the pre-licensing report to the Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. "Pre-licensing is complete and this facility has no deficiencies"

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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