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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701165
Report Date: 07/27/2023
Date Signed: 07/27/2023 12:09:48 PM

Document Has Been Signed on 07/27/2023 12:09 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SAFE HAVEN TRUSTED CARE 2FACILITY NUMBER:
342701165
ADMINISTRATOR:HERNANDEZ, WINNIEFACILITY TYPE:
735
ADDRESS:5195 EHRHARDT AVETELEPHONE:
(916) 431-7209
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 4CENSUS: 4DATE:
07/27/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Winnie HernandezTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/27/23 at 8:45AM to conduct a Post Licensing visit. LPA met with Winnie Hernandez and explained the purpose of the visit.

The facility is licensed for a capacity of 4 ambulatory residents of which 1 may be non-ambulatory in room #4. LPA observed 3 residents and 1 is at day program during this visit.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility.

LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises.

The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 113.4*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.


Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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