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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804048
Report Date: 06/20/2022
Date Signed: 06/21/2022 09:12:06 AM


Document Has Been Signed on 06/21/2022 09:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SAFE HAVEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
486804048
ADMINISTRATOR:POQUIZ, AILEENFACILITY TYPE:
740
ADDRESS:118 FAIRFAX COURTTELEPHONE:
(510) 224-6165
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
06/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Aileen PoquizTIME COMPLETED:
04:53 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Pre-Licensing Inspection and was greeted by Applicant, Administrator, Aileen Poquiz.

This facility received Fire Department clearance approval on 3/2/2022 for a total capacity of 6 residents, of which 4 residents can be non-ambulatory and 2 residents may be ambulatory in bedroom #3. LPA conducted a walk-through of the facility and observed, facility is a single story house with 4 resident bedrooms, 1 staff room, 2 bathrooms, common spaces and garage. Resident rooms are furnished per regulation with a bed, lamp, dresser, and bedside table. Bathroom showers have non-skid shower mats and grab bars. There was a locked area for medications and for resident and personnel files. Perishable and non-perishable foods observed and applicant understands food requirements per regulation. The laundry area is located in garage and it has a locked cabinet to secure toxins & cleaning supplies. Water temperature is within regulation of 105 to 120 degrees. Facility backyard has covered area for visiting and activities. The outside shed is locked with pad lock. Facility has emergency lighting in hallways and an emergency flashlights. First Aid Kit is available. Facility has working fire alarms, carbon monoxide and the extinguisher was charged and serviced on 1/13/2022. Facility states and understands the fireplace will not be used, unless it meets regulation.
The facility has an entry table to screen visitors for Covid-19 with a thermometer, hand sanitizer, masks, a sign in log and some covid posters.

Pre-licensing is complete and this facility has no deficiencies.
The Component III Orientation was completed with applicant during this visit.

LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; facility requires proof of liability insurance. Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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