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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202428
Report Date: 12/27/2023
Date Signed: 01/04/2024 07:55:41 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/22/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210722153920
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: 27DATE:
12/27/2023
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Elizabeth EspiqueTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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On 12/27/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Caregive Elizabeth Espique and explained the purpose of today's visit.

Regarding the allegation that the facility has pests, the reporting party (RP) stated that the facility is infested with beetles, roaches, and bed bugs.

During the investigation, LPA Yatfai Ng, was able to obtain photos of different bite marks on residents from bugs. While touring the facility, it was observed that the cupboards in the kitchen had dead bed bugs and live flies and roaches. LPA also interviewed residents. Two out of two residents mentioned that there were bed bugs sometimes. Staff helped spray the room, but the bed bugs kept returning. Exterminators came but the bed bugs still come back. A staff member (S1) confirmed that there were pests in the facility.

Licensee has been addressing issues with regards to pest infestations. Any report from residents, an exterminator will be scheduled to visit immediately.

Based on interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewes and a copy of this report and the Appeal Rights are provided.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20210722153920
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: STONE HAVEN CARE
FACILITY NUMBER: 435202428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2023
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Licensee has addressed the issue by scheduling an exterminator every 2 weeks or as needed.
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This requirement was not met as evidenced by: Based in interviews and record reviews, the Licensee failed to address complaints that the facility had a pest infestation, which poses an immediate health, safety, or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2