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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201318
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:28:39 PM

Document Has Been Signed on 01/16/2024 02:28 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLCFACILITY NUMBER:
079201318
ADMINISTRATOR:POQUIZ, AILEENFACILITY TYPE:
740
ADDRESS:960 GRIFFITH LANETELEPHONE:
(510) 224-6165
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 0DATE:
01/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Aileen Poquiz and Ramandeep SidhuTIME COMPLETED:
02:45 PM
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On 1/16/2024 at 10:00 AM, Licensing Program Analysts (LPAs) J. Sampair and T. Syess-Gibson arrived announced to conduct a prelicensing inspection of the facility with Aileen Poquiz and Ramandeep Sidhu. Upon arrival, the LPAs identified themselves and verified the purpose of the meeting with the Applicants.

The LPAs and Applicants completed the prelicensing inspection of the facility inside and outside and the COMP III training.

Pre-Licensing is complete.

Exit interview conducted and a copy of this report was provided via email to Applicants.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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