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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201409
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:27:31 PM

Document Has Been Signed on 10/02/2024 03:27 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SAFE HAVEN OAKLEY LLCFACILITY NUMBER:
079201409
ADMINISTRATOR/
DIRECTOR:		ALEJO, RYAN QFACILITY TYPE:
740
ADDRESS:228 GOLDEN STATE PARKWAYTELEPHONE:
(408) 772-0256
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 6CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Ryan Alejo, Administrator and Raman Deep, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 10/2/2024 at 2:30pm Licensing Program Analyst (LPA) L. Hall conducted an announced pre-licensing inspection. LPA met with Ryan Alejo, Administrator and Raman Deep, Licensee. The facility has a fire clearance for two (2) ambulatory and four (4) non-ambulatory. A hospice waiver for four (4) residents.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and back yard. The facility has a total of four (4) bedrooms, three (3) bathrooms. There were no bodies of water present during inspection. There is sufficient lighting around the facility. Residents rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars. Passageways and hallways are free of obstruction. Locked cabinets available to store medications and toxins. Locked cabinet to store sharps. Hot water temperature is measured at 109.7 degrees Fahrenheit. Fire extinguisher was last serviced on 04/22/2024. Carbon monoxide and smoke detectors present. First-Aid kit was observed complete. Facility inspection matches the sketch that was provided.

Licensing Program Manager (LPM), H. Humpal gave approval to waive Comp III.

No issues were noted during inspection. LPAs observed that facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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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