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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435601018
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:37:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SAFE HAVEN VILLA CARE HOMEFACILITY NUMBER:
435601018
ADMINISTRATOR:THELMA LLANESFACILITY TYPE:
740
ADDRESS:5670 JUDITH STREETTELEPHONE:
(408) 809-4131
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 1DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Thelma LlanesTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Thelma Llanes Administrator.

LPA toured the facility inside and out to include the entry, bedrooms, bathroom, kitchen, dining room, living room and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in locked cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathroom observed to be supplied with hygiene products. Hand sanitizer available. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, training, PPE usage and Fit Testing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Thelma Llanes Administrator and a copy of this report emailed for signature due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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