<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608562
Report Date: 04/27/2024
Date Signed: 04/27/2024 12:17:55 PM

Document Has Been Signed on 04/27/2024 12:17 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
Lookup Error,
, CA
FACILITY NAME:SENIORS' HAVEN LLCFACILITY NUMBER:
197608562
ADMINISTRATOR/
DIRECTOR:		JORGE ADLE MENDOZAFACILITY TYPE:
740
ADDRESS:1831 NORTH KENWOOD STREETTELEPHONE:
(818) 843-3572
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 0DATE:
04/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Jorge Adle Mendoza-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:16 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/27/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Jorge Adle Mendoza/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. Of which (6) may be non-ambulatory. Bedroom #4. Approved hospice waiver for (2). Currently the facility has no clients in care.

The facility is a 1 story structure with 4 bedrooms, 2 bathrooms, kitchen, dining area, family room, and living room/office area.

LPA toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (4) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable conditions. The water temperature properly measured between 105F. and 120F.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SENIORS' HAVEN LLC
FACILITY NUMBER: 197608562
VISIT DATE: 04/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning agents, poisons, and sharps objects were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable.

A review of (0) residents' service files, (1) staff personnel files were checked. (0) Medication Administration Records (MAR) were reviewed.

LPA observed the facility's infection control practices. Copy of liability insurance was provided to LPA during this visit. Facility Annual Fess not current. LPA told administrator that the license fees are not current since 3/8/24.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Jorge Adle Mendoza/Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2