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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005856
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:15:34 AM

Document Has Been Signed on 10/31/2024 11:15 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/
DIRECTOR:		CALMA, RHODAFACILITY TYPE:
740
ADDRESS:1221 SIERRA VISTA DRTELEPHONE:
(562) 228-4439
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 6CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Rhoda CalmaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Nancy Guillen for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Rhoda Calma and discussed the purpose of the inspection.

LPAs reviewed Infection Control requirements. At about 8:05AM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 6-bathroom, two-story house with detached garage that is used for storage. There is a back yard with a patio cover for the residents. LPAs observed 2 staff and 5 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the one staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 106 degrees F and 111 degrees in the 5 bathrooms used by residents. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:05AM, LPAs reviewed 5 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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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Document Has Been Signed on 10/31/2024 11:15 AM - It Cannot Be Edited


Created By: Sean Haddad On 10/31/2024 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HAVEN FOR MOM & DAD 1
FACILITY NUMBER: 306005856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not ensure rubbing alcohol and medications were inaccessible to residents in the closet and kitchen cabinet, which poses an immediate health risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they will ensure all dangerous items in the facility are secured, train staff on securing dangerous items, and submit proof to LPA by POC due date.
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, there was a resident living in the room marked as office on the facility sketch, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 11/01/2024
Plan of Correction
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Licensee stated they will relocate the resident into a resident bedroom.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/31/2024 11:15 AM - It Cannot Be Edited


Created By: Sean Haddad On 10/31/2024 at 10:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HAVEN FOR MOM & DAD 1
FACILITY NUMBER: 306005856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility has two stories with a staff bedroom on the second floor and does not have an evacuation chair, which poses a potential safety risk to persons in care.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee stated they will purchase and install an evacuation chair on the second floor and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HAVEN FOR MOM & DAD 1
FACILITY NUMBER: 306005856
VISIT DATE: 10/31/2024
NARRATIVE
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During the inspection, LPAs and AD observed the following: Based on observation, the licensee did not ensure rubbing alcohol and medications were inaccessible to residents in the closet and kitchen cabinet; based on observation, there was a resident living in the room marked as office on the facility sketch; and based on observation, the facility has two stories with a staff bedroom on the second floor and does not have an evacuation chair.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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