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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804048
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:43:53 PM


Document Has Been Signed on 07/22/2024 01:43 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: 0DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Aileen Poquiz, Licensee TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived to conduct a Required - 1 Year inspection. The facility is licensed for a total of 6 residents, of which 4 may be Non-ambulatory, with a hospice waiver to allow 3 residents on Hospice services and no approval for bedridden residents/rooms.

LPA toured facility and grounds and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. All smoke detectors and carbon monoxide detectors are operational. Water temperature in resident bathrooms measured between acceptable range of 105 to 120 degrees F. 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.
Administrator, submitted a current lease agreement and this facility is the process of sumitting a change of ownership application. Licensee understands facility must operate as a residential facility for the elderly, with a capacity of no more than 6 residents, as per their license.

Administrator certificate for Aileen Poquiz, #6060598740 expires 2/14/2025 LPA discussed their Emergency Disaster Plan and Infection Control Plan.
Licensee/Administrator to submit the current following documents by 8/22/2024:
· 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: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024
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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