<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801311
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:12:09 PM


Document Has Been Signed on 10/12/2022 01:12 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:HAAVE HOUSEFACILITY NUMBER:
565801311
ADMINISTRATOR:BONNIE M. HAAVEFACILITY TYPE:
740
ADDRESS:315 RIVERSIDE ROADTELEPHONE:
(805) 649-0704
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:6CENSUS: 5DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Bonnie Haave/LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 At 11:35am on 10/12/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility. LPA was screened at the front door for COVID-19 protocols. LPA met Licensee Bonnie Haave and announced who he was as the reason for the visit.

At 11:45am LPA and Licensee conducted a cursory tour of the facility. This facility is a 7 bedroom, 2 bathroom with one room designated as staff bedroom (#2 bedroom), there is a dinning room kitchen area, and living room. There is ample out door area in the back yard with shade for residents in care. LPA observed fire detectors in each room to be working with green light lit. LPA observed the carbon monoxide detector to be working properly. LPA noted that the facility has at least 2 days of perishable and 7 days of nonperishable foods on hand for the 5 residents in care. LPA noted that the facility water temature to be in regulation parameters (95*-120*f). LAP observed the facility to be clean and in good repair. LPA noted that there were no obstructions in the facility that would create a hazards for residents in care. LPA noted that this cursory inspection walk through did not indicate any deficiencies or citations at this time.

At 12:30pm Licensee and LPA conducted the infection control module of the annual inspection. LPA noted that there were no deficiencies or citations noted on the infection control module of the annual inspection visit.

Exit interview, report signed, and report emailed .



SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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 1