435201885-7-29-2025-26-AS-CKAI-DK2VHV-20250729162747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201885
Report Date: 07/29/2025
Date Signed: 07/29/2025 04:27:55 PM

Document Has Been Signed on 07/29/2025 04:27 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	NEW HAVEN RESIDENTIAL CARE FACILITY #2		FACILITY NUMBER:	435201885
ADMINISTRATOR/ DIRECTOR:	DARLINGTON ODJEGBU		FACILITY TYPE:	735
ADDRESS:	5842 CADIZ DRIVE		TELEPHONE:	(408) 578-8804
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 2	DATE:	07/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:25 PM
MET WITH:	Darlington Odjegbu		TIME VISIT/ INSPECTION COMPLETED:	04:30 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) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator (ADM), Darlington Odjegbu. During visit, LPA toured the facility with ADM to include 3 resident bedrooms, 1 bathroom, office room, garage, living room, kitchen and backyard. All fire exit routes were free and clear of obstruction. There were 2 residents to 3 staff members present during visit. The 3 staff members present are fingerprint cleared and associated to the facility. ADM states they have 1-2 awake night staff per 2-3 residents. Facility temperature maintained at 68 degrees F. Fire extinguisher last serviced on 06/30/2025. Carbon monoxide detector observed operable. The fire place in the dining room observed covered and screened. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. The facility did not have a thermometer in the refrigerator/freezer. LPA used the state provided thermometer to measure the temperatures in both areas. Refrigerator temperature maintained at 53.6 degrees F. Freezer temperature maintained at 32.4 degrees F. Sharp objects and medications observed locked. Chemicals and disinfectants observed locked in the kitchen and stored separately from the food supply. All emergency exits observed with a door alarm. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: NEW HAVEN RESIDENTIAL CARE FACILITY #2	FACILITY NUMBER: 435201885
	VISIT DATE: 07/29/2025

NARRATIVE

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LPA reviewed 2 resident files. 2 out of 2 resident files observed complete and up-to-date to include an admissions agreement, annual needs and services plan, physician's report, TB result, identification and emergency contact information, safeguard of personal property and valuables form, and personal rights. LPA reviewed 2 out of 2 resident's centrally stored medications and centrally stored medication records, no issues were noted. 2 out of 2 resident's P&I money was counted with the staff and ADM, and all money was accounted for and accurately logged.

LPA reviewed 3 staff files. 3 out of 3 staff files observed complete to include an active first aid certification, health screening, TB result, and job application. 3 out of 3 staff are provided training and holds an active administrator certificate.

Facility has an emergency disaster plan. LPA advised ADM to ensure the emergency disaster plan is reviewed annually. 2 first aid kits observed complete. Facility has emergency bins filled with non-perishable foods, flashlight, radio, drinking water, blanket, and paper supplies. The residents also has a grab-and-go backpack which contains extra clothing. Additional flashlights and emergency lighting observed in the hallway. Emergency drills are completed quarterly and the last drill was completed on June and July 2025. Personal protective equipment (PPE) supplies observed to include gowns, gloves, face masks, hand sanitizer and disinfectants. Facility has an infection control plan. LPA advised ADM to ensure the infection control plan is reviewed annually.

Documents were requested to update the facility file:
- Emergency disaster plan (LIC610D)
- Infection Control Plan
- Lease Agreement

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D

This report was reviewed with Administrator (ADM), Darlington Odjegbu and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2025 04:27 PM - It Cannot Be Edited

Created By: Christine Kabariti On 07/29/2025 at 04:15 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 CARE FACILITY #2	FACILITY NUMBER: 435201885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

85076(d)(4)

(d) The licensee shall meet the following food supply and storage requirements: (4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above wherein the refrigerator temperature was maintained at 53.6 degrees F and freezer temperature maintained at 32.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2025
	Plan of Correction
1 2 3 4	Licensee states a plan to buy a new refrigerator/freezer, ASAP. Licensee will submit a receipt of the purchase to LPA Kabariti via email by POC due date of 07/30/2025.

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.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC809 (FAS) - (06/04)

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