435601018-10-24-2025-26-AS-MPAA-DMS3VC-20251024183456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435601018
Report Date: 10/24/2025
Date Signed: 10/24/2025 06:35:11 PM

Document Has Been Signed on 10/24/2025 06:35 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:	10/24/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Thelma Llanes - Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:30 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, conducted an unannounced visit to continue the facility required 1-year inspection, met with the licensee/administrator (LIC/ADM) Thelma Llanes and stated the purpose of the visit. The purpose of today's visit is to issue citations based on the deficiencies that was observed during last visit that was conducted on 10/17/2025. Based on record review 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. Based on record review LIC/ADM could not provide proof of the emergency preparedness and disaster training. 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 does not possess an updated training for care of residents with dementia. Last training was administered on June 2019 for facility staff. Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22. See LIC9099-D. An exit interview was conducted with LIC/ADM Thelma Llanes, a copy of the report was provided. end of report.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

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

Document Has Been Signed on 10/24/2025 06:35 PM - It Cannot Be Edited

Created By: Maria Partoza On 10/24/2025 at 05:30 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: SAFE HAVEN VILLA CARE HOME	FACILITY NUMBER: 435601018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(b)(1)

87705 Care of Persons with Dementia (b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on document review, the licensee did not comply with the section cited above by not ensuring staff are receiving the following training as part of the training requirement specified in Section 87208 Plan of Operation. S1 training was given in 2019 and S2 does not have onboarding training since S2 started at the facility in July of 2024, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2025
	Plan of Correction
1 2 3 4	LIC/ADM stated that she will submit a written plan of correction by the due date 10/25/2025, LIC/ADM stated that he/she will be providing training on dementia care based on 87208 plan of operation for facility that serves residents with dementia. Proof of training will be submitted to LPA by 10/31/2025.

Type A

Section Cited

CCR

87458(c)(1)(A-D)

87458 Medical Assessment (c) The medical assessment shall include… (1)A physical examination of the resident indicating…diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. (B)Infectious diseases. (C) Contagious diseases. (D)Other medical conditions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above by not providing medical assessment for 2 residents (R2 & R4) and 1 staff (S2) with results of examination for the following communicable tuberculosis, Infections diseases, contagious diseases and other medical condition which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2025
	Plan of Correction
1 2 3 4	LIC/ADM stated that he/she will submit a written plan of correction by the date of 10/25/25. LIC stated that he/she will complete and provide proof of medical assessmen for R2 and R4 and health screening for S2 by 10/28/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/24/2025 06:35 PM - It Cannot Be Edited

Created By: Maria Partoza On 10/24/2025 at 06:18 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: SAFE HAVEN VILLA CARE HOME	FACILITY NUMBER: 435601018
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above by not conducting a drill for each shift, the type of emergency covered under HSC 1569.695. LIC/ADM do not have proof of training and have stated that the training has not been provided for almost a year. Which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2025
	Plan of Correction
1 2 3 4	LIC/ADM stated that he/she will submit a written plan of correction by the due date of 10/25/25. LIC/ADM plan to provide actual training by giving staff specific assignment during training in the event of an emergency (disaster, fire and earthquake). LIC/ADM will document quarterly training drills and will submit first proof of training on or before 10/31/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4