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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201318
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:51:37 PM

Document Has Been Signed on 01/22/2025 04:51 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/
DIRECTOR:		POQUIZ, AILEENFACILITY TYPE:
740
ADDRESS:960 GRIFFITH LANETELEPHONE:
(510) 224-6165
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 3DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jose Eden De la Cruz, Care StaffTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 01/22/205 at 11:15AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Care Staff, Jose Eden De la Cruz and explained the purpose of the visit. The facility’s fire clearance was approved for five (5) non ambulatory and one (1) ambulatory residents.

LPA toured the facility with Jose De la Cruz, Care staff including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three and half (3 1/2) bathrooms. four (4 bedrooms for residents, two (2) staff bedroom. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 106.0 degrees Fahrenheit. Residents’ bathrooms are equipped nonskid mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last service on 11/11/2024. Emergency Disaster Plan was last posted on 01/22/2025. First aid kit was observed to be complete. Fire drill conducted on 12/12/2024.

Continue LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318
VISIT DATE: 01/22/2025
NARRATIVE
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Continued from LIC809.

Three (3) staff records were reviewed S2 and S3 were missing health screenings and S3 was not fingerprint cleared and associated to facility. LPA reviewed all three (3) resident records which were complete.

The following deficiencies observed during visit.
  • At 11:32AM, LPA observed R1, R2 and R3 had half bed rails.
  • At 11:37AM, LPA observed no grab bars installed in shower of residents’ shared bathroom.
  • At 11:43AM, LPA observed pledge multi surface spray, gorilla spray adhesive heavy duty, BAR spray and foam hardwood floor cleaner, Lysol sanitizer spray, The pink stuff- miracle cleaning paste, and maintex all-in-one multi surface cleaner in an unlocked cabinet under the kitchen sink.
  • At 11:47AM, LPA observed R2 is in an ambulatory room, R2 is non ambulatory.
  • At 11:51AM, LPA observed five (5) one (1) gallon BAHR paint and primer buckets and DAP pre-mixed stucco repair in garage with a turn lock.
  • At 1:45PM, LPA observed during record review S2 and S3 were missing Health Screenings and S3 wasn’t associated or fingerprint cleared. LPA asked S3 to leave facility.


The following forms to be updated and submitted to CCLD by 01/29/2025:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 500 (updated)
  • LIC 610D Emergency Disaster Plan
  • Updated facility sketch


Continued from LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318
VISIT DATE: 01/22/2025
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Continued from LIC809C.

*The total amount of civil penalties assessed on today's date $500.00 for staff (S3) not being fingerprint cleared.

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy the appeal rights, LIC421FC and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/22/2025 04:51 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/22/2025 at 03:35 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: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
80019 Criminal Record Clearance
80019(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review... prior to working...in a licensed facility: Request a transfer of a criminal record clearance...

This requirement was not met as evidence by:

Deficient Practice Statement
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3
4
Based on record review, licensee did not comply with S3 being associated to the facility which poses an immediate health and safety risk to the clients in care.
POC Due Date: 01/23/2025
Plan of Correction
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3
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S3 was asked to leave the facility. Administrator has agreed to obtain fingerprint clearance for S3 prior to S3 returning to the facility. Administrator will submit correspondence with CCLD regarding S3's clearance or S3's live scan form to CCLD by POC date.
Civil penalty of $500 is being assessed
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


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Document Has Been Signed on 01/22/2025 04:51 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/22/2025 at 03:40 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: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having R2 who is non ambulatory in an ambulatory room which poses an immediate health, safety risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Administrator agreed to move R2 to an non ambulatory room and send a self certifying email to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/22/2025 04:51 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/22/2025 at 03:46 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: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in having pledge multi surface spray, gorilla spray adhesive heavy duty, BAR spray and foam hardwood floor cleaner, Lysol sanitizer spray, The pink stuff- miracle cleaning paste, and maintex all-in-one multi surface cleaner in an unlocked cabinet under the kitchen sink. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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Care Staff immediately locked kitchen cabinet with items. Deficiency cleared during visit.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2025 04:51 PM - It Cannot Be Edited


Created By: Tonica Syess-Gibson On 01/22/2025 at 03:55 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: SAFE HAVEN BRENTWOOD RESIDENTIAL CARE HOME, LLC
FACILITY NUMBER: 079201318

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(5)(A)
87608 Postural Supports
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in not having an doctor orders for half bed rails for R1, R2 and R3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Administrator agreed to email CCLD doctor orders or invoice for hospital beds with half rails by POC date.
Type B
Section Cited
CCR
87412(a)(11)
87412 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:
(11) A health screening as specified in Section 87411, Personnel Requirements - General.

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 in not having S2 and S3 health screening in personnel files which poses a potential health and safety rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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3
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Administrator agreed to have all staff health screenings in personnel files and will send CCLD a self certifying email by POC date.
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:Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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