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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920154
Report Date: 07/23/2024
Date Signed: 07/23/2024 12:08:04 PM

Document Has Been Signed on 07/23/2024 12:08 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFE HAVEN NATOMAS LLCFACILITY NUMBER:
345920154
ADMINISTRATOR/
DIRECTOR:
GRIMESEY RICHARD A.FACILITY TYPE:
740
ADDRESS:5070 TUCKERMAN WAYTELEPHONE:
(510) 224-7357
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 0DATE:
07/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Aileen Poquiz Grimesey, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On July 23, 2024, at 10am, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Aileen Poquiz Grimesey, Administrator, who assisted LPA in today’s inspection. The Administrator certificate expires. The current census is 0. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 82 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to Document Link Iconthe residents at all times. Hot water temperatures were taken and measured at 120 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

The facility is a one-story home with 5 bedrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. Hot water temperature is 120 degrees F. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFE HAVEN NATOMAS LLC
FACILITY NUMBER: 345920154
VISIT DATE: 07/23/2024
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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. The facility was observed to have been inspected on 4/22/2024 by Fire Code and in compliance at this time. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The administrator has an updated CPR and First Aid Certificates.

The Disaster Plan is posted along with emergency numbers, complaint filing procedures facility theft and loss policy, and resident’s personal rights.



LPA's did not conduct Component III. Licensee has another facility in Brentwood, CA.

Licensure pending approval from Central Application Unit .

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.
An exit interview was conducted and a copy of this report was given to Aileen.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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