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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202428
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:20:43 PM

Document Has Been Signed on 12/01/2022 04:20 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: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: 30DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Administrator, Chidi (Goody) IkemeTIME COMPLETED:
04:30 PM
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On 12/1/2022 at 3:30pm, Licensing Program Analyst (LPA) Simi Rai conducted an unannounced annual inspection and met with Elizabeth Espique, Lead Caregiver and Administrator Chidi (Goody) Ikeme.

LPA Rai 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 Rai reviewed the facility policies and procedures to include screening, visitation, disinfecting, training, and PPE supplies.

LPA Rai observed the hand soap supply to be running low. Administrator Goody stated he will pick up hand soap to replenish the resident bathrooms. LPA Rai advised Administrator to place hand washing signs on the rest of the resident bathrooms.

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

This report with reviewed with Administrator Chidi (Goody) Ikeme and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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