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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610327
Report Date: 12/05/2024
Date Signed: 12/05/2024 02:21:11 PM

Document Has Been Signed on 12/05/2024 02:21 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/
DIRECTOR:		HOROWITZ, JESSICAFACILITY TYPE:
740
ADDRESS:10507 ANDASOL AVETELEPHONE:
(818) 324-7536
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 3DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Jessica HorowitzTIME VISIT/
INSPECTION COMPLETED:
11:48 AM
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Licensing Program Analysts (LPAs) Nadia Shahbazian and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Jessica Horowitz, and explained the reason for the visit.

With ith the assistance of the administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. The carbon monoxide detector is installed in the living room. It functions properly. The fire extinguisher located in the kitchen is fully charged.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning supplies are locked underneath the kitchen sink.

Bedrooms: There are four (4) bedrooms designated for residents' use. The bedrooms that are occupied by the residents were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. LPAs did not observe any cleaning supplies or hazardous items stored in either of the bathrooms in use by the residents. Hot water temperature signs compliant with regulation.

Common Areas: These included the living room and dining area. The living room had a couch, two tables and a television. The dining room table is large enough to seat up to six residents. Passageways and hallways were clear obstruction. Floors were mopped and clean. The auditory alarms on all exit doors were on and functional at the time of the visit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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: HAVEN HOMES
FACILITY NUMBER: 197610327
VISIT DATE: 12/05/2024
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a storage building, in the backyard, which was checked and was locked.

Laundry Area: The laundry area is located by the kitchen. LPA did not observe detergents to be accessible at the time of the visit.

Garage: Facility does not have a garage. It was converted into staff room.

Staff Room/Work Station: Staff room is located next to the laundry area. Staff room is inaccessible to the residents in care.

Resident Files: Resident files are kept locked in a cabinet by the living room. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Resident files are kept locked in a cabinet by the living room. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication cabinet is located by the dining room. Medication and Medication Records were review for proper storage, locks and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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