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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202428
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:35:23 PM

Document Has Been Signed on 10/25/2024 01:35 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:
10/25/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Staff - Elizabeth EspiqueTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/25/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced plan of corrections (POC) visit in conjunction with multiple complaint visits on this day. LPA met with staff person Elizabeth Espique and explained the purpose of this visit.

LPA observed the kitchen which is pest and cockroach fee based on observations. There are no bed bugs in the facility per staff interviews and client reports to staff. The facility has since hired pest control such as Western Exterminator and HeatRX to treat the pest issued previously reported via complaint received on 06/27/2022 complaint number 26-AS-20220627122422.

A citation is cited today with the associated complaint number 26-AS-20220627122422 and is also cleared on this same day.

No further citations are issued. POC letter generated and provided to facility staff person Elizabeth Espique.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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