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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850510
Report Date: 09/06/2024
Date Signed: 09/06/2024 01:22:57 PM

Document Has Been Signed on 09/06/2024 01:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAFE HAVEN SENIOR LIVINGFACILITY NUMBER:
195850510
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, CRISTINAFACILITY TYPE:
740
ADDRESS:14417 BURTON STREETTELEPHONE:
(818) 486-8846
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 0DATE:
09/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Cristina HernandezTIME VISIT/
INSPECTION COMPLETED:
01:46 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit at 9:53 a.m. and met with the applicants Haig Boghosian and Cristina Hernandez. This is a new facility application for a Residential Care Facility for the Elderly (RCFE). Fire Clearance was approved on 08/05/2024 for six (6) non-ambulatory residents. At 10:03 a.m., the LPA, and the applicants toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives will be stored in a locked and inaccessible kitchen drawer; however, a lock needs to be installed. A seven-day supply of non-perishable food was available, water supply needs to be added to the seven-day supply of food. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink; however, a lock needs to be installed. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Two fire extinguishers were observed; one is located near the kitchen area and one in the hallway leading to the bedrooms. Applicant will attach a copy of the purchase receipt to each one of the fire extinguishers.

BEDROOMS: There are five (5) bedrooms for residents in care, and two (2) bedrooms for staff. Rooms 1, 2, 3, and 4 are designated as single/private rooms, and bedroom five (5), is designated as a shared bedroom. All residents’ bedrooms need window screens, and window curtains/blinds. Rooms 6 and 7 are designated for staff. All residents’ bedrooms are cleared for non-ambulatory. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and drawer space available. Bedroom #5 needs to be reconfigured so that the bathroom door does not hit side of one of the beds.
Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAFE HAVEN SENIOR LIVING
FACILITY NUMBER: 195850510
VISIT DATE: 09/06/2024
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PG. 2
BATHROOMS: There are four (4) bathrooms. Bathroom (#1) is in the hallway for staff and visitors. Bathroom (#2) is a shared bathroom for bedroom #5. Bathroom #5 needs to have shower floor cleaned and hole on the bottom of the shower wall covered. Bathrooms (#3 and #4) are shared bathrooms between bedrooms 4, 3, 2, and 1. All bathrooms are equipped with toilet and shower grab bars. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Nonskid mats will be added to the shower area in all three bathrooms. Bathroom door in bedroom #4 needs to be level to allow for easy opening and closing. Hand washing signs as reminder of good hygiene, and paper towels to prevent cross-contamination will be added to all four bathrooms.
COMMON AREAS: These include a living room space which is equipped with a television and a dining area. A fireplace is located in the dining area and has a fireplace covering. There is a dedicated area for the posting of required documents. The licensing poster will be replaced with 16” X 24” poster. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Residents’ and staff files will be stored and locked in the Staff/Office room. Linen closet is in the hallway. Night-lights will be installed in the hallways. Emergency exiting plan needs to be updated to reflect emergency meeting area.

GARAGE/LAUNDRY ROOM: There is a laundry area equipped with washer and dryer. Detergents and cleaning supplies will be stored in a locked cabinet above the washer and dryer. The laundry area is located in the garage. The facility has an attached garage. The door will be kept locked at all times.
OUTDOOR/SURROUNDING GROUNDS: The fire exit exterior passageway needs to be clean of debris and remove trash cans. Protruding ground pipes need to be removed/shaved to ground level. Water pipes need to be covered. The patio area has a shade; however, at the time of the visit the patio is in need of a patio table and chairs for residents’ use. An opening next to the patio wall needs to be covered. In the front of the house yard, bricks were observed be loose and need to be secured. The building has a central entrance for residents and visitors; however, no ramp was observed in the front entrance, or the kitchen entrance. All residents would need to use either one of the two ramps adjacent to the bedrooms’ hallway to get to the common areas of the facility. A ramp with handrails will need to be installed in the common area’s sliding door leading to the shaded patio area. A gate will need to be installed at the back of the house next to the garage area to prevent residents from wondering to a back passageway, which is deemed unsafe to residents in care, due to the Air Conditioning (AC) unit and other electrical cables. Cars, trucks and all construction equipment will be cleared from the outdoor patio area. Continues on LIC 809 C... page 3.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAFE HAVEN SENIOR LIVING
FACILITY NUMBER: 195850510
VISIT DATE: 09/06/2024
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Pg. 3

Pre-Licensing is incomplete with deficiencies to be resolved by Friday, September 27th, 2024.and LPA will return for a follow up visit.

At 01:05 p.m., the applicant completed Component III orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.



SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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