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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201409
Report Date: 05/14/2025
Date Signed: 05/14/2025 02:43:42 PM

Document Has Been Signed on 05/14/2025 02:43 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
OAKLAND ASC, 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: 4DATE:
05/14/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Emarita Morales, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On 05/14/2025 at 11:50AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced post licensing inspection. LPA met with Emarita Morales, Caregiver. Emarita contacted Administrator, Ryan Alejo via telephone and advised purpose of visit. Administrator arrived at 2:00PM.

LPA toured facility including but not limited to bedrooms, bathrooms, dining area, living room, kitchen, garage, and outdoor area. Fire extinguisher was observed to be full and last serviced on 04/15/2025. Medications were in a locked closet in hallway. Comfortable room temperature is maintained at 73 degrees F. Hot water temperature in the shared residents’ bathroom was measured at 109.1 degrees Fahrenheit.

LPA observed One week of non-perishable and 2-day perishable food supplies were sufficient. Carbon monoxide and smoke detectors were observed in operating condition. First-aid kit was complete, and hygiene items for resident general use are sufficient. Extra linens and towels were observed in the hallway closet. Last fire drill was conducted on 2/26/2019. There are no accessible bodies of water observed.




Continue on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE HAVEN OAKLEY LLC
FACILITY NUMBER: 079201409
VISIT DATE: 05/14/2025
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Continued from LIC809

LPA reviewed all four (4) residents records, and four (4) staff records and they were all complete. All staff are fingerprint cleared, has FirstAid/CPR and associated to the facility.


The following forms to be updated and submitted to CCL by 05/21/2025:
  • LIC 500- Personnel Report
  • LIC 308- Designation of Facility Responsibility
  • LIC 610E- Emergency/Disaster Plan (9 pages)
  • Evidence of Liability Insurance


  • At 2:00PM, LPA observed during record review, staff members does not have the required training and Dementia Care training
  • At 2:10PM, LPA observed during file review three(3) out of four (4) residents does not have doctor's orders for bedrails.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.


Exit interview conducted. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Tonica Syess-Gibson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/14/2025 02:43 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 05/14/2025 at 02:14 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SAFE HAVEN OAKLEY LLC
FACILITY NUMBER: 079201409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in not having staff members trained and training documents in staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Administrator agreed to provided training to all staff from a CCL approved vendor and submit training materials and staff sign sheet to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in not having doctor orders for three(3) out of four(4) residents bedrails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Administrator agreed to send CCL a copy of the doctor orders for resident's bedrails by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/14/2025 02:43 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 05/14/2025 at 02:14 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: SAFE HAVEN OAKLEY LLC
FACILITY NUMBER: 079201409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(b)(1)
Care of Persons with Dementia
(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in not having staff trained on care of persons with dementia which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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3
4
Administrator agreed to provided training to all staff from a CCL approved vendor and submit training materials and staff sign sheet to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Tonica Syess-Gibson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2025


LIC809 (FAS) - (06/04)
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