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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202241
Report Date: 03/21/2025
Date Signed: 03/21/2025 01:22:54 PM

Document Has Been Signed on 03/21/2025 01:22 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/
DIRECTOR:		EDNA G. ORIBELLOFACILITY TYPE:
735
ADDRESS:1222 WAGON WAYTELEPHONE:
(408) 848-6205
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 4DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Alma BuclatinTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year 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.

Facility temperature maintained at 71 degrees Fahrenheit. Bedrooms supplied with proper linens and furniture to include beds, dressers, night stands, and lamps. Bathroom is equipped with grab bars and hygiene supplies. The bathroom sink has a warning sign stating that the water temperature may be over 125 degrees F. ADM states the water takes about 10 minutes to heat up. LPA measured the hot water temperature between 104 - 107 degrees F after 5 minutes of running the hot water. Facility's has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 40 degrees F. Freezer temperature maintained at 0 degrees F. Disinfectants and chemicals stored in a separate area away from the food.

Facility equipped with an operable Carbon Monoxide detector. Fire extinguisher was last services on 04/04/2024. Facility has a first aid kit. Emergency disaster drills are completed monthly and the last drill was completed in February 2025. Each resident has a grab and go backpack in case of an emergency.

See LIC809-C.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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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: 03/21/2025
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LPA reviewed 4 residents files and observed the files complete and up to date. 4 residents medications and centrally stored medication records were reviewed and all medications was accounted for. 2 out of 4 resident's P&I money was counted and all money was accounted for.

LPA reviewed 3 staff files and observed the files complete and up to date. 3 staff are fingerprint cleared and provided 1st aid certification. Staff are provided annual training.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Alma Buclatin and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025
LIC809 (FAS) - (06/04)
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