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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606737
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:29:46 PM

Document Has Been Signed on 06/21/2022 02:29 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A HEAVENLY HAVEN, INC. IIFACILITY NUMBER:
197606737
ADMINISTRATOR:FRANCISCA RECEDEFACILITY TYPE:
740
ADDRESS:20000 LASSEN STREETTELEPHONE:
(818) 775-9397
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 6DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Francisca Recede TIME COMPLETED:
02:40 PM
NARRATIVE
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On 06/21/22 at 1:00 p.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Francisca Recede. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 1:05 p.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff took LPA’s temperature upon arrival. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet in the kitchen area. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 1:20 p.m. and appear to be functional. Fire extinguisher has a purchase date of 03/29/22. Common Areas: All common areas were observed to be clean and properly furnished. Resident Rooms: Facility has seven (7) bedrooms which of six (6) are designated for resident use. Facility has no live-in staff. The 7th bedroom is used for a staff break/rest area. All seven (7) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture.

Continue on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A HEAVENLY HAVEN, INC. II
FACILITY NUMBER: 197606737
VISIT DATE: 06/21/2022
NARRATIVE
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Bathrooms: There are three (3) bathrooms in the facility of which all three are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured at 138.9F. LPA informed staff that the water had to be correct immediately as it does not fall in regulation. All trash cans located in the bathrooms had tight fitting lids. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water. Garage: There is a detached garage area that is being used for additional storage. LPA observed two rooms inside the garage. Both rooms contained beds and personal items belonging to staff. Administrator stated that no one is sleeping in the rooms. LPA also observed a bathroom in the garage with personal items such as toothbrushes and other toiletries.

The following deficiencies were observed and cited per Title 22 see attached LIC 809D

Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2022 02:29 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 06/21/2022 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC. II
FACILITY NUMBER: 197606737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

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87303 Maintenance and Operation (e)(2)
Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by
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Based on observation, the licensee did not comply with the section cited above in ensuring the water temperature was kept within regulation for residents' use which poses immediate health, safety or personal rights risk to persons in care.
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Type B
06/28/2022
Section Cited

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87305(b) Alterations to Existing Building or New Facilities. The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.
This requirement is not met as evidenced by
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Based on observation and interviews, licensee failed to ensure proper permits were acquired prior to having the non permitted garage use, which poses a potential health and safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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