435601018-10-23-2025-26-AS-MPAA-DMQRYG-20251023132616

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435601018
Report Date: 10/17/2025
Date Signed: 10/23/2025 01:27:40 PM

Document Has Been Signed on 10/23/2025 01:27 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 VILLA CARE HOME		FACILITY NUMBER:	435601018
ADMINISTRATOR/ DIRECTOR:	THELMA LLANES		FACILITY TYPE:	740
ADDRESS:	5670 JUDITH STREET		TELEPHONE:	(408) 809-4131
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY: 6		CENSUS: 4	DATE:	10/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Thelma Llanes - Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:00 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	Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with administrator (LIC/ADM) Thelma Llanes. LPA stated the purpose of the visit. The facility is licensed to serve adults 60 and over, approved for 6 non-ambulatory and waiver for 2 hospice and 1 bedridden. LPA observed 4 residents present at the facility that have neurocognitive disorder, Staff 1 was attending to the needs of the resident. LPA toured the facility inside and outside with ADM including but not limited to the kitchen, bathroom, dining room, living room, 4 residents rooms, garage, staff room, backyard and exterior walkways. LPA observed that the facility sun room is currently under construction for repairs. The ramp was sturdy and no planks missing, not obstructed by any debris. The outdoor covered patio area has exercise equipment and construction equipment that are no longer in use and not accessible for resident's enjoyment. The kitchen, dining room, living room and entry way is kept maintained, sanitary and organized. The bathroom/s are equipped with grab bars, non-skid mats. Resident's room have sufficient storage. Knives and sharps were locked and not accessible to residents. Medications are in a locked cabinet. LPA observed 2 days of perishable food,however the 7 day non-perishable food is not sufficient to sustain 4 resident and 2 staff in the event of an emergency. ADM scheduled the food purchasing for 10/18/25. see lic 809C Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

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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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)

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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: SAFE HAVEN VILLA CARE HOME	FACILITY NUMBER: 435601018
	VISIT DATE: 10/17/2025

NARRATIVE

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The temperature inside the home was at 73 degrees Fahrenheit. The water temperature in the bathroom measured between 105.8 degree Fahrenheit and kitchen water temperature is measured at 107.8 degree F.
LPA observed 3 refrigerator/freezer combination. The refrigerator temperature is 32 degree F and freezer is at 0 degree F.

The facility is equipped with 4 camera located in the kitchen, dining, living area and hallways. No camera was observed inside the resident rooms. LPA observed smoke and carbon monoxide alarm. The fire alarm wired to detect smoke or fire. ADM stated that the camera are not recording any audio.

LPA reviewed 4 resident record, 4 out of 4 resident record is missing personal rights, 2 out of 4 has no TB on record, 2 out of 4 are missing medical assessment, 4 out of 4 are missing pre-admission appraisal forms, 1 out of 4 is missing the Centrally Stored Medication and Destruction Record (CSMDR), 4 out of 4 is missing the personal valuable list. 2 Out of 4 resident does not have an updated appraisal needs and services plan.
4 Out of 4 does not have the emergency identification sheet. 4 Out of 4 does not have the consent form to release medical information in the event of an emergency.

LPA reviewed the facility file, ADM was not able to provide proof of the emergency preparedness and disaster training drill. 1 Out of 2 staff record was reviewed. 1 out of 2 does not have a 1st Aid/CPR training 1 out of 2 does not have on boarding training, 2 out of 2 have no medical training that are updated. Last training was administered on June 2019.

Due to time constraint the annual inspection will be continued and citations will be issued based on today's inspection observation and document reviews based on California Code of Regulations (CCR) Title 22 for staff training, personnel requirement, health and safety, building maintenance, food service, resident records and facility record.

LPA suggested for administrator to reach out to Technical Support Program offered by the Department.
An exit interview is conducted with administrator Thelma Llanes and a copy of the report was provided.

end of report
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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025

LIC809 (FAS) - (06/04)

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