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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005856
Report Date: 12/02/2021
Date Signed: 12/02/2021 11:19:32 AM

Document Has Been Signed on 12/02/2021 11:19 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HAVEN FOR MOM & DAD 1FACILITY NUMBER:
306005856
ADMINISTRATOR:CALMA, RHODAFACILITY TYPE:
740
ADDRESS:1221 SIERRA VISTA DRTELEPHONE:
(562) 228-4439
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 6CENSUS: 6DATE:
12/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rhoda CalmaTIME COMPLETED:
11:36 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was screened for symptoms of Covid-19 and granted entry. LPA explained the reason for the visit. LPA met with Administrator Rhoda Calma. LPA and Administrator toured the facility. Facility is a 2 story house with 5 bedrooms, 1 office and 6 bathrooms. Rhoda Calma's Administrator's Certificate expires 7/10/2023. LPA observed all resident bedrooms had the required furnishings and had enough space to accommodate the residents and their belongings. LPA observed all bedrooms were clean and organized. LPA observed all bathrooms were clean and operational. Smoke detectors/carbon monoxide detectors tested operational. LPA observed a 2 day perishable and 7 day non-perishable food supply in the kitchen. The kitchen is clean and organized. LPA observed knives and sharp objects are kept locked in a kitchen drawer. LPA observed medication kept locked in a cabinet. LPA and Administrator inspected the garage. The garage is kept locked and off limits to residents. The garage is used to store extra food and supplies. LPA and Administrator toured the backyard. LPA observed both exit gates are operational. No bodies of water observed. There is a covered patio and a sitting area with a table and chairs to sit outside. No obstacles or hazards observed in the backyard. Facility has submitted a mitigation plan that has been approved No deficiencies are being cited as a result of todays visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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