<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202428
Report Date: 08/27/2025
Date Signed: 08/27/2025 01:59:35 PM

Document Has Been Signed on 08/27/2025 01:59 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:
08/27/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Elizabeth Espique, Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 08/27/2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management - Other visit. Upon arrival, LPA met with Lead Caregiver, Elizabeth Espique and talked to the Administrator, Chide Ikeme over the phone, and disclosed the purpose of the visit.

On 07/23/2025, 08/05/2025, and 08/20/2025, the LPA conducted Complaint investigations at the facility for complaint #26-AS-20250716083606, #26-AS-20250804104755, and #26-AS-20250814143020.

On 07/23/2025 and 08/20/2025, LPA interviewed the Administrator, who stated that a case manager had reported that a resident (R1) was diagnosed with scabies by R1’s physician and no medical documentation was provided by the case manager or R1. The Administrator further stated that the Administrator did not request or obtain R1’s doctor’s After Visit Summary report and did not report the suspected or confirmed case of scabies to CCL or the CDPH. The Administrator also stated that the bed bugs had been an ongoing issue at the facility for approximately five years.

On 07/23/2025, 9 out of the 13 residents interviewed stated that they have either seen bed bugs on their beds and clothes or experienced bed bug bites over the past several months.

On 08/20/2025, 5 out of 5 residents interviewed reported seeing bed bugs or experiencing bed bug bites.

On 07/24/2025, LPA obtained and reviewed a copy of R1’s doctor’s After Visit Summary report, dated 07/09/2025, confirming that R1 had been diagnosed with scabies.

On 07/23/2025, during the facility visit, LPA observed R1 in their room. R1 was scratching their arms, neck, and other areas. Visible red and brown rashes were observed on R1’s arms, hands, feet, and face.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: 08/27/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 08/20/2025, LPA obtained and reviewed a copy of R2’s doctor’s After Visit Summary report, dated 08/07/2025, which confirmed that R2 had been diagnosed with bed bug bites.

On 08/20/2025, during the facility visit, LPA observed R2 in their room. R2 displayed visible bed bug bites. LPA inspected R2’s mattress and observed clustered dark-colored spots.

On 08/05/2025, LPA obtained and reviewed the facility’s internal incident reports for July 2025. The incidents of resident-to-resident altercations and police detaining a resident were documented.

On 08/20/2025, the LPA reviewed the facility’s records for past Incident Reports and found that no reports had been submitted to CCL regarding R1’s scabies diagnosis and bed bug issues at the facility. There were no Incident Reports submitted to CCL for resident-to-resident altercations and police detaining a resident.

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and the Plan of Correction was reviewed and developed with the Administrator over the phone. A copy of this report and appeal rights were discussed and left with the Lead Caregiver, Elizabeth Espique, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/27/2025 01:59 PM - It Cannot Be Edited


Created By: Kiran Jain On 08/27/2025 at 01:51 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: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2025
Section Cited
CCR
80061(b)(1)(E)

1
2
3
4
5
6
7
80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. (1) Events reported shall include the following: (E) Any unusual incident…which threatens the physical or emotional health or safety of any client.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator stated that they will conduct all staff in-service training on "Reporting Requirements" and will submit the evidence of in-service training to CCL by the POC due date of 09/03/2025. The evidence of training must include the trainer's name, title of training, time or length of training, name and signature of all employees/staff.
8
9
10
11
12
13
14
Based on observations, interviews conducted, and records reviewed, the facility staff didn’t submit incident reports regarding bed bug infestation, resident complaints of bed bugs, suspected/confirmed case of scabies, resident-to-resident altercations, and resident detained by the police to the CCL department, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4