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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:35:13 PM

Document Has Been Signed on 05/05/2023 12:35 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR:ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 3DATE:
05/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:MARILOU LADABANTIME COMPLETED:
01:00 PM
NARRATIVE
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On 05/05/2023 at 8:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to continue the Required Annual Inspection began on 05/04/2023. Upon entry, LPA disclosed the purpose of the visit with Lead Staff Marilou Ladaban.

After reviewing the previous day's inspection report, LPA attempted a review of facility, resident, and personnel records. However, LPA was informed by Ms. Ladaban that an insufficient number of records were readily available for him to continue with his record review. Consequently, he stopped his review and issued a B-Type deficiency (refer to LIC809-D for details)

Exit interview conducted and a copy of this report provided via email.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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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Document Has Been Signed on 05/05/2023 12:35 PM - It Cannot Be Edited


Created By: James Sampair On 05/05/2023 at 12:25 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87755(c)
87755 INSPECTION AUTHORITY OF THE LICENSING AGENCY (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having facility, personnel, and resident records available for LPA to inspect during regular business hours, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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On or before due date, Licensee shall inform LPA that all facility, personnel, and resident records have been made available at the facility for LPA to inspect during regular business hours.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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