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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202922
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:29:39 PM


Document Has Been Signed on 04/24/2024 12:29 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:SAFE HAVEN CARE HOMES LLCFACILITY NUMBER:
435202922
ADMINISTRATOR:GRIMESEY, RICHARDFACILITY TYPE:
740
ADDRESS:859 S WOLFE RDTELEPHONE:
(408) 813-1025
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY:6CENSUS: 0DATE:
04/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Applicant Aileen GrimeseyTIME COMPLETED:
12:35 PM
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Licensing Program Analyst Manuel Monter (LPA) conducted an announced pre-licensing inspection and met with Applicant (AP) Aileen Grimesey. There are no residents present on site.

During visit, LPA toured the facility with AP, including living room, 5 resident bedrooms, garage, kitchen/dining room 3 bathrooms, and backyard. LPA observed the garage being used as a storage space/ Laundry area.

Facility was observed to be clean and in good repair. Fire exit routes were clear and free of obstructions. Carbon monoxide detectors was tested and observed to be functioning properly. Fire extinguisher was purchased in September 27, 2023. Bathroom hot water temperature was measured at 118 degrees F. Facility temperature observed to be 68*F. Bathrooms were observed to be stocked with soap and paper towels. First Aid Kit observed to be complete. No open bodies of water noted at facility.

Medication cabinet observed to be locked. Facility kitchen equipment is functioning properly, LPAs observed locked drawer for sharps. LPAs reviewed emergency disaster plan and confirmed its completeness. LPAs observed storage closed for containment of cleaning chemicals. Facility bulletin board contain all necessary documents. No issues noted during this Pre-Licensing Inspection.

LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Component III orientation was conducted with Applicant Aileen Grimesey. This report was reviewed with Applicant Aileen Grimesey and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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