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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606737
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:19:48 PM

Document Has Been Signed on 11/07/2023 01:19 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:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Francisca Recede, AdministratorTIME COMPLETED:
01:00 PM
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At 10:20am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit.

At 10:25am LPA conducted a tour of the physical plant and observed the following:

Facility is a Residential Care Facility for the Elderly which was licensed for capacity of six (6) of which three (3) non-ambulatory and one (1) bedridden residents. Facility has six (6) bedrooms designated for residents use, four (4) bathrooms and one staff room. Facility has been approved for a hospice waiver for four (4) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. . Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 74°F. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 119.1°F. Extra towels and linens were readily available. The fire extinguisher was observed in the living room area and was last serviced on 03/27/2023. Laundry area is also located by the kitchen area and LPA observed all chemicals and detergents are kept locked and inaccessible to residents. Facility has a permitted Accessory Dwelling Unit (ADU) in the backyard that is fenced all around with a gate and kept locked at all times. LPA also observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 11:00am to 12:00pm, LPA reviewed records of three (3) residents and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.
No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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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