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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801311
Report Date: 12/16/2024
Date Signed: 12/16/2024 02:20:37 PM

Document Has Been Signed on 12/16/2024 02:20 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/
DIRECTOR:
BONNIE M. HAAVEFACILITY TYPE:
740
ADDRESS:315 RIVERSIDE ROADTELEPHONE:
(805) 649-0704
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Administrator, Bonnie HaaveTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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At 8:30am on 12/16/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Licensee/Administrator, Bonnie Haave, announced who he is and the reason for the visit.
This facility has 7 bedroom, 6 of the rooms are single resident occupancy, and the 7th bedroom is a live-in staff bedroom. Facility bedrooms were properly equipped per regulations including additional linins. There are two bathrooms that are shared bathrooms. Bathrooms were stocked with liquid soap and paper towels. The main entrances is in the front of the facility and there is a side entrance. There are two hallways in the facility, one adjacent to the main entrance and one that leads from the living room, medications are stored and locked in a cabinet in the facility hallway leading from the living room. There are tables with umbrellas in the back of the facility and there is a covered side porch with seating for activities and visitors for residents and visitor. There a is a living room, dining room and kitchen at the front of the facility. LPA observed at least 2 days of perishable foods and at least 7 days of non perishable foods for 6 residents and staff. LPA noted that there is a fire extinguisher mounted in the kitchen area that is primed in the green. LPA noted that there are functioning smoke detectors in each resident room. LPA noted that there is a working carbon monoxide detector located in the facility hallway next to the air vent. LPA observed required facility posting in the facility hallway near the main entrance. LPA conducted a sample medication audit, reviewed staff, and resident files. LPA reviewed Emergency Disaster (LIC610) and Infection Control Plans (LIC9282) with Administrator and singed for annual review.
LPA and Administrator conducted a full review of the annual control tools modules. LPA noted that there were no citations or violations issued as a result of the facilities annual physical inspection and the annual control tools modules. LPA conducted 2 staff and 4 client interviews.

Exit interview, report read and report provided.
Kelly BurleyTELEPHONE: (805) 562-0413
Mark JeffriesTELEPHONE: (805)562-0400
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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