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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804048
Report Date: 06/27/2023
Date Signed: 06/28/2023 01:02:11 PM


Document Has Been Signed on 06/28/2023 01:02 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
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: 6DATE:
06/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Alicia Poquiz and Richard Grimesey, co-licenseeTIME COMPLETED:
05:14 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, office manager, Alicia Poquiz. Richard Grimesey, co-licensee arrived a few minutes later. There are currently 6 residents in care, this facility is licensed for a total of 6 residents, with a hospice waiver to allow all 3 residents on Hospice services and no approval for bedridden residents/rooms. LPA toured the building and grounds which were found to be clean and in good repair. During today's visit there were 6 residents living in the home.

LPA toured facility and grounds and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged and serviced on May 2, 2023. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in resident bathrooms measured at 110 degrees and is within acceptable range of 105 to 120 degrees F.
There was sufficient perishable and non-perishable foods located in the kitchen and garage and food is stored properly. Medications were centrally stored and locked. Medication Assessment Records (MARS) were reviewed during the inspection and were found to be appropriate. Cleaning products and other toxins are locked and inaccessible to residents in care. There was a supply of Linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all resident bedrooms was conducted, and bedrooms inspected have lighting and appropriate furnishing.

Resident and staff files were reviewed and in compliance. Staff have the required training and proof of CPR/1st expiring October 2024. Administrator certificate for Aileen Poquiz, #6060598740 was renewed and waiting for certificate.
Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 486804048
VISIT DATE: 06/27/2023
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 LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 7/21/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Liability Insurance


No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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