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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701433
Report Date: 01/17/2025
Date Signed: 01/17/2025 02:00:42 PM

Document Has Been Signed on 01/17/2025 02:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFE HAVEN OAKDALE LLCFACILITY NUMBER:
502701433
ADMINISTRATOR/
DIRECTOR:		GRIMESEY, AILEEN POQUIZFACILITY TYPE:
740
ADDRESS:2912 WESTPORT CIRCLETELEPHONE:
(510) 224-6165
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 6DATE:
01/17/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Alex Vincent Popanes, Caregiver TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 01/17/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to conduct a post-licensing inspection. LPA Campbell met with Vince Popanes and explained the purpose of the visit.

The facility is a single story facility licensed for 6 non-ambulatory and hospice residents over 60. There are 4 bedrooms. Of the 4 bedrooms, 2 are shared rooms and 2 are private rooms. One of the shared rooms has an en suite bathroom. Occupants of the rest of the rooms use the bathroom in the hallway. There is no body of water found on the facility. The facility sketch shows no alterations in comparison to the building during the visit.

Upon Entry, LPA Campbell observed a sign in sheet in the entry. A See Something, Say Something poster and Ombudsman poster were on the wall. Certificate #6060598740 for administrator Aileen Poquiz was framed as well. It expires on 02/14/2025. The facility was odor free and free of debris. The fire extinguisher was last inspected on March 21, 2024.

LPA Campbell conducted a tour of the premises that included but was not limited to the dining room, bedrooms, bathrooms, common area and backyard. The dining rooms and common areas were furnished appropriately. Bedrooms contained the appropriate items including beds, chests, closets, chairs, night stand and lamp. The thermostat was observed at 71 degrees Fahrenheit (F). Water was measured at 115 degrees F. The Pantry contained enough food to last the residents seven days. Perishable foods were observed to be enough to last residents 3 days. The outside area and the pathway to the fire exit was free of obstacles. A shaded area was observed with seating and a table. The smoke alarm was tested and found to be functioning. Knives were observed to be locked in a lower cabinet in the kitchen. Of the 6 residents, 4 of their files were reviewed and found to be complete.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SAFE HAVEN OAKDALE LLC
FACILITY NUMBER: 502701433
VISIT DATE: 01/17/2025
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No staff files were found at the facility. When copies of files were requested, the administrator offered to email the records. However, they could not be provided within a reasonable amount of time and had not arrived by 2:00 pm.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.
 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 02:00 PM - It Cannot Be Edited


Created By: Renee Campbell On 01/17/2025 at 12:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFE HAVEN OAKDALE LLC
FACILITY NUMBER: 502701433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2025
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance. Prior to working,... in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
This requirement is not met as evidenced by:
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Effective Immediately, but no later than 01/17/2025; the Administrator shall remove S2 from the facility and have all employees fingerprinted, complete a health screening and TB test prior to returning to work by POC date. Written certification is required to show Administrator has read regulation by POC date.
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Based on record review, the licensee did not ensure a criminal record clearance was obtained for 1 of 2 staff members (S2) present in the facility, which poses an immedicated Health, Safety or Personal Rights risk to persons in care.
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Type A
01/27/2025
Section Cited
CCR87412(g)

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87412 (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
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Administrator will ensure staff files are present, complete and easily available to staff and LPA for review by POC date.
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LPA and staff were unable to find complete staff files on premises for review. Of the one file found, the paperwork is incomplete.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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