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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197606737
Report Date:
10/26/2022
Date Signed:
10/26/2022 02:50:50 PM
Unsubstantiated
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2022
and conducted by Evaluator
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20221019120003
FACILITY NAME:
A HEAVENLY HAVEN, INC. II
FACILITY NUMBER:
197606737
ADMINISTRATOR:
FRANCISCA RECEDE
FACILITY TYPE:
740
ADDRESS:
20000 LASSEN STREET
TELEPHONE:
(818) 775-9397
CITY:
CHATSWORTH
STATE:
CA
ZIP CODE:
91311
CAPACITY:
6
CENSUS:
4
DATE:
10/26/2022
UNANNOUNCED
TIME BEGAN:
09:45 AM
MET WITH:
Francisca Recede
TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
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3
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9
Facility is not kept clean
Staff store food items with cleaning solutions
Facility's air conditioner is in disrepair
Staff are not ensuring that the facility is free of pests
Staff are not ensuring that medications are centrally stored
Staff do not properly maintain records of centrally stored medication
INVESTIGATION FINDINGS:
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9
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13
Licensing Program Analyst(s) Wendell Smith and Joscelyn Martinez conducted an initial complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit. Administrator was contacted and joined the visit shortly thereafter.
Facility is not kept clean
It is alleged that the facility is dirty and unkempt. LPA's conducted a physical plant tour from 9:45-10:30am. During the physical plant tour LPA's observed the facility to be clean and in good order. Interviews were conducted with staff regarding this allegation. Based on information obtained through observation this allegation is deemed Unsubstantiated at this time.
Staff store food items with cleaning solutions
Regarding this allegation LPA's conducted a physical plant walk through. LPA's observed cleaning solutions and food items to be stored separately. LPA observed cleaning solutions to be locked away and inaccessible from residents. Based on information obtained through observation this allegation is deemed Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099
(FAS) - (06/04)
Page:
1
of
3
Control Number
31-AS-20221019120003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMPLAINT INVESTIGATION 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:
10/26/2022
NARRATIVE
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Facility's air conditioner is in disrepair
It is alleged that the facility's air conditioner does not work. During the physical plant inspection LPA's checked and observed the air conditioner to be working properly. LPA's also spoke with staff regarding the air conditioner. Based on the information obtained through observation and interviews this allegation is deemed Unsubstantiated at this time.
Staff are not ensuring that the facility is free of pests
It is alleged that facility has an issue with roaches. During the physical plant walk through LPA's did not observe any roaches or pest in the facility. Interviews were conducted with residents and staff regarding this allegation. Based on the information obtained through observation and interviews this allegation is deemed Unsubstantiated at this time.
Staff are not ensuring that medications are centrally stored
It is alleged that resident#1 (R1) has medications stored in their room when they are not supposed to. LPA checked R1's room during the physical plant walk through and observed that R1 did have medication in their room. LPA's checked R1's physician report which indicated that R1 was able to handle their own medications. Based on the information obtained through record review this allegation is deemed Unsubstantiated at this time.
Exit Interview conducted. Copy of report issued.
SUPERVISORS NAME
:
Cassandra Harris
LICENSING EVALUATOR NAME
:
Wendell Smith
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/26/2022
LIC9099
(FAS) - (06/04)
Page:
2
of
3