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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202241
Report Date: 04/12/2023
Date Signed: 04/12/2023 04:05:33 PM

Document Has Been Signed on 04/12/2023 04:05 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:SACRED HAVEN CARE HOME INC.FACILITY NUMBER:
435202241
ADMINISTRATOR:EDNA G. ORIBELLOFACILITY TYPE:
735
ADDRESS:1222 WAGON WAYTELEPHONE:
(408) 848-6205
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
04/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Alma BuclatinTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Administrator (ADM), Alma Buclatin.

During visit, LPA toured the facility to include the dining room, kitchen, living room, resident bedrooms, bathrooms, garage, and backyard. All fire exits and passageways were free and clear of obstruction. All staff present and live-in staff are fingerprint cleared and associated to the facility.

Facility's kitchen equipped with clean plates, cups, bowls, utensils, and cooking supplies. Sharp objects observed locked. Disinfectants and chemicals stored in a separate area away from the food. Hot water temperature in the kitchen maintained at 118 degrees Fahrenheit. Facility's refrigerator and freezer is not equipped with a thermometer. LPA advised to ensure the facility has a thermometer to maintain proper temperature. ADM stated understanding. LPA observed the facility's reusable containers were covered with lids and properly labeled. Facility has at least seven days worth of non-perishable foods and two days worth of perishables foods.

Facility temperature maintained at 68 degrees Fahrenheit. Bedrooms supplied with proper linens and furniture to include beds, dressers, night stands, and lamps. Bathrooms supplied with hygiene products and hand washing sign.

Facility equipped with an operable Carbon Monoxide detector. Fire extinguisher was last services on 03/08/2023. First aid kit supplied with tweezer, scissors, thermometer, Band-Aids, and gauze.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2023
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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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: SACRED HAVEN CARE HOME INC.
FACILITY NUMBER: 435202241
VISIT DATE: 04/12/2023
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LPA reviewed residents (R1 - R4) files to include the following: admission agreement, physician's report, needs and services plan, IPPs, emergency form, personal rights, weight record, immunization record, consent form, safeguard of personal property and valuables, cash resources, and centrally stored medications records.

LPA reviewed staff (S1 - S3) files to include the following: LIC501, employee rights, LIC508, LIC503, 1st Aid Certification, and training records.

Poster and signs observed to include if you see something say something, emergency disaster plan, emergency disaster exit strategies, resident roster, designated administrator, and COVID-19 related posters.

LPA interviewed 3 residents and 2 staff.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Administrator, Alma Buclatin and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023
LIC809 (FAS) - (06/04)
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