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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202241
Report Date: 03/23/2024
Date Signed: 03/23/2024 12:02:24 PM

Document Has Been Signed on 03/23/2024 12:02 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:
03/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator/House Manager Alma BuclatinTIME COMPLETED:
12:15 PM
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At 9:00 a.m. of 3/23/2024, Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility and conducted an unannounced required 1 year inspection and met with administrator/house manager (HM) Alma Buclatin, administrator (ADM) Edna Oribello was not available during the time of visit per HM, ADM was on scheduled time off.

ADM/HM stated they have 5 residents in the facility and 3 staff.

At 9:05 a.m. 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 is within range of 105 to 120 degree F. Facility's refrigerator and freezer is equipped with thermometer and temperature is maintained at 38 degree F and 0 degree F respectively. 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. The bathroom hot water temperature measured between 105 to 120 degree F.

Facility temperature maintained between 68 to 71 degree F. Bedrooms supplied with proper linens and furniture to include beds, dressers, night stands, and lamps. Bathrooms supplied with hygiene products and hand washing sign.

page 1 continued to page 2 LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2024
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
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: 03/23/2024
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Facility equipped with an operable Carbon Monoxide and smoke detector. Fire extinguisher was last services on 03/08/2023 and will be re-inspected by end of March 2023. First aid kit supplied with tweezer, scissors, thermometer, Band-Aids, and gauze.

LPA reviewed residents (R1 - R3) 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 - S2) 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. A copy of the signed report was reviewed with ADM/HM Alma Buclatin and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2024
LIC809 (FAS) - (06/04)
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