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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200506
Report Date: 08/23/2023
Date Signed: 08/23/2023 11:13:46 AM

Document Has Been Signed on 08/23/2023 11:13 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HERITAGE HAVENFACILITY NUMBER:
019200506
ADMINISTRATOR:FERDINAND GUTIERREZFACILITY TYPE:
740
ADDRESS:389 JUANA AVENUETELEPHONE:
(510) 357-1300
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 27CENSUS: DATE:
08/23/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jhemierly Morales, CaregiverTIME COMPLETED:
11:20 AM
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On 8/23/2023 at 10:05am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Jhemierly Morales, Caregiver, and explained the purpose of the visit. Administrator, Ferdinand Guiterrez, arrived at 10:50am.

LPA conducted a case management visit on 8/10/2023 and cited facility for the following:

  • Broken window - LPA observed during today's visit window have been replaced.
  • Broken cabinet door - LPA observed cabinet doors have been repaired.
  • Broken exit door - LPA observed door have been repaired.
  • Fire extinguisher - Administrator submitted photo that fire department check extinguisher on 8/14/2023.
  • Food - LPA observed food and also receipts for additional food delivery for today
  • First aid certification for staff - LPA observed first aid and CPR certification for all three (3) staff.
  • Appraisal needs and services plan for clients - Plans have been updated for clients

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: HERITAGE HAVEN
FACILITY NUMBER: 019200506
VISIT DATE: 08/23/2023
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Continued from LIC809.

LPA observed that all deficiencies have been corrected, except the training for the staff. LPA extended the POC date to September 11, 2023, to complete training.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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