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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202428
Report Date: 12/20/2021
Date Signed: 12/20/2021 12:00:05 PM

Document Has Been Signed on 12/20/2021 12:00 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:STONE HAVEN CAREFACILITY NUMBER:
435202428
ADMINISTRATOR:CHIDI IKEMEFACILITY TYPE:
735
ADDRESS:578 N. MATHILDA AVE.TELEPHONE:
(408) 481-9920
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 33CENSUS: 28DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elizabeth EspiqueTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Christine Dolores conducted an unannounced annual inspection to include infection control site visit and met with Elizabeth Espique, Lead Caregiver.

LPA toured the facility inside and out to include the courtyard, dining room, kitchen, office, client rooms, bathrooms, laundry room, and backyard. All fire exit routes were free and clear of obstructions.

Facility observed to have designated entry point for clients, staff, and visitors. The following posters were observed to include social distancing, symptoms of COVID, required masks, and hand washing. Facility has a designated visitation area. LPA observed supply of Personal Protective Equipment (PPE). LPA reviewed the facility policies and procedures to include screening, visitation, disinfecting, training, and PPE supplies.

The Department will provide PPE supplies. LPA will provide additional COVID-19 resources.

No citations were issued per the California Code of Regulations, Title 22. Advisory Notes provided.

This report with reviewed with Elizabeth Espique, Lead Caregiver and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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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