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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202428
Report Date: 10/15/2024
Date Signed: 10/15/2024 04:28:35 PM

Document Has Been Signed on 10/15/2024 04:28 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/
DIRECTOR:		CHIDI IKEMEFACILITY TYPE:
735
ADDRESS:578 N. MATHILDA AVE.TELEPHONE:
(408) 481-9920
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 33CENSUS: 32DATE:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Elizabeth EspiqueTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On October 15, 2024, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility at 01:00 PM to conduct the Annual 1-year required inspection. LPA met with Elizabeth Espique, caregiver and explained the purpose of the visit. Chidi Ikeme, Administrator joined shortly after.

LPA toured the facility in the presence of a staff member, including resident bedrooms, bathrooms, common areas, kitchen, and outdoor spaces. Fire extinguishers were fully charged and last serviced on 07/08/2024. Two smoke and carbon monoxide detectors were tested and found operational.

The facility’s emergency disaster plan was reviewed. All exits, common areas, and outdoor spaces were observed clear of obstructions. No hazards or accessible bodies of water were observed.

The kitchen and pantry were inspected, with 7 days of non-perishable food and 2 days of perishable food available. No expired food items were observed, and open food items were properly wrapped. Sharp objects, chemicals, and hazardous materials were locked and inaccessible.

LPA randomly inspected resident rooms and bathrooms. Rooms contained required furniture and working lighting. Hot water temperatures in bathrooms measured between 106.7°F and 114.4°F. The laundry room was observed to be locked and is accessible for staff members only.

Five resident files were reviewed and found complete. Medications were securely stored, and Centrally Stored Medication Logs for five residents were audited and found complete.

At 2:45 PM, LPA reviewed six personnel records and 6 out 6 staff members have expired First Aid Certificate, which poses a potential safety risk to persons in care.

At 3:14 PM, LPA was unable to review emergency drill logs as Administrator was not able to show evidence/logs of emergency drills being conducted at the facility, which poses a potential safety risk to persons in care.

The First Aid kit was inspected and contained the required supplies.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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: STONE HAVEN CARE
FACILITY NUMBER: 435202428
VISIT DATE: 10/15/2024
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The following updated forms are requested to be submitted to CCLD by 10/22/2024:
· LIC 500: Personnel Report
· LIC 308: Designation of Facility Responsibility
· Administrator Certificate
· Surety Bond
· Certificate of Liability Insurance

The deficiencies were cited under Title 22 of the California Code of Regulations. Failure to correct the deficiencies by the due date may result in civil penalties. See LIC 809-D for details.

This report was reviewed with Chidi Ikeme, Administrator, and a copy, along with appeal rights, was provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 04:28 PM - It Cannot Be Edited


Created By: Kiran Jain On 10/15/2024 at 04:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: STONE HAVEN CARE
FACILITY NUMBER: 435202428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the licensee did not comply with the section cited above in 6 out 6 staff members have expired First Aid Certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Administrator plans to register all 6 staff members online for the first aid certificate and send LPA the proof of registration and eventually pictures of valid first aid certificates.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA was unable to review emergency drill logs as Administrator was not able to show evidence/logs of emergency drills being conducted at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Administrator plans to conduct an emergency drill and send a log to the LPA with details on the drill that was conducted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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