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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610327
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:16:56 PM

Document Has Been Signed on 09/12/2022 03:16 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:HAVEN HOMESFACILITY NUMBER:
197610327
ADMINISTRATOR:HOROWITZ, JESSICAFACILITY TYPE:
740
ADDRESS:10507 ANDASOL AVETELEPHONE:
(818) 324-7536
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
09/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jessica HorowitzTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct a pre-licensing inspection visit. LPA was greeted by the facility administrator and the inspection tool was used to complete the visit.

The home is a 4 bedroom 2 bath house. There are 2 shared rooms and 2 single rooms. There is no swimming pool or other bodies of water on the property. The smoke alarms and carbon monoxide detectors were tested and functioned properly. All doors are equipped with noise activation and all doors functioned properly.

Component III was also completed during today's visit.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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