<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201749
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:48:33 PM

Document Has Been Signed on 12/19/2024 04:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:NEW HAVEN RESIDENTIAL FACILITYFACILITY NUMBER:
435201749
ADMINISTRATOR/
DIRECTOR:		ODJEGBU, DARLINGTONFACILITY TYPE:
735
ADDRESS:4428 STONE CANYON DRIVETELEPHONE:
(408) 226-2016
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 3DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Darlington OdjegbuTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Darlington Odjegbu.

Two staff and two resident were observed in the facility.

Two resident files and two staff files were reviewed.

LPA toured the facility with ADM inside and out. LPA inspected living room, dinning area, kitchen and garage. There are 2 restrooms, 1 office, and 3 resident rooms in facility. Two days perishable foods and seven day nonperishable foods were observed sufficient. Room temperature was observed at 71 degree F, hot water temperature was observed at 116 degree F. Medication cabinet, Knife closet were observed locked. Dish washing soap bottle was observed on the top of the sink in the kitchen. ADM put the dish washing soap bottle in the cabinet under the sink and locked it immediately. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system and carbon monoxide detectors were tested, and were working fine. Fire extinguisher was serviced on 6/26/2024.

First aid box and emergency light system were observed in the facility. The last time the facility conducted the earthquake drill was on 12/2/2024, and the last time the facility conducted the fire drill was on 12/3/2024.

Front yard and backyard were inspected. One storage room was observed at the backyard. There was no obstruction to block the walkways.

Deficiency noted for today's inspection visit. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 12/19/2024 04:48 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 12/19/2024 at 03:40 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: NEW HAVEN RESIDENTIAL FACILITY
FACILITY NUMBER: 435201749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)(1)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. (1) Such assessment shall be performed by a licensed physician, or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that the physician reports of 2 Out of 2 resident files were found physician reports older than one year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/26/2024
Plan of Correction
1
2
3
4
Administrator stated to submit a plan of correction by the POC due date to ensure to maintain all clients' physician report up to date and within one year. Administrator agreed to make doctor appointments for residents R1 and R2.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4