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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610626
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:54:18 AM

Document Has Been Signed on 10/24/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A PEACEFUL HAVEN RESIDENTIAL COMMUNITYFACILITY NUMBER:
197610626
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ, CLAUDIAFACILITY TYPE:
740
ADDRESS:13641 FENTON AVETELEPHONE:
(818) 262-3871
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Claudia Gutierrez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted a Pre-Licensing Inspection at this facility and met with the applicant representative/Administrator Claudia Gutierrez. The applicant is " A Peaceful Haven Residential Community, Inc.". A fire clearance was approved on 09/11/24 for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room #1. The applicant has an approved hospice waiver for six (6) residents.

The facility is a single story house with a total of three (3) bedrooms and three (3) bathrooms. A tour of the physical plant was initiated at approximately 9:55 AM and the following was observed:

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of emergency food. Knives will be locked in a kitchen drawer. Cleaning supplies and other toxins are stored in the garage which was locked during visit.

BEDROOMS: There are three (3) bedrooms designated for clients' use, all are shared bedrooms. The applicant furnished the residents' bedrooms with beds, night stand, chairs, dressers, bedding and linen. The bedrooms have sufficient lighting and storage.

BATHROOMS: The facility has two (2) shared bathrooms for clients' use. One (1) bathroom is designated for staff use. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature was measured at a range of 112.7°F to 115.7°F.

LAUNDRY ROOM: The laundry room is located in the garage. Laundry detergents and other cleaning agents were locked in a cabinet in the garage. The cleaning supply cabinet was observed to be locked during visit. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: A PEACEFUL HAVEN RESIDENTIAL COMMUNITY
FACILITY NUMBER: 197610626
VISIT DATE: 10/24/2024
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(continued from LIC 809)

COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The living room area was furnished with a television, a coffee table and sofas to sit the capacity of the facility. There were no visible immediate hazards. There is a working telephone line and internet access to residents. Dual smoke/carbon monoxide alarms were tested and observed to be operable, they are hardwired and interconnected. Fire extinguisher was last bought on 07/27/24 and located in the kitchen area.

MEDICATIONS: The medication cabinet is located in the bedroom hallway and has a locking mechanism. A complete first aid kit is located in the kitchen.

Staff/Resident Records: Staff and resident records will be kept in the filing cabinet the staff lounge/office/staff break room.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a covered patio and backyard furniture to accommodate the residents. The Garage is converted into an office/staff break room/laundry area. There is a tool shed on the backyard separated by a 3' gate and inaccessible to residents. There are drive way in front of the facility which could park three (3) cars at a time.

Component III was conducted with the Licensee representatives.

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.

Exit interview conducted. Copy of this report.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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