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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201513
Report Date: 05/13/2026
Date Signed: 05/13/2026 03:59:32 PM

Document Has Been Signed on 05/13/2026 03:59 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:SAFE HAVEN ROSE GARDEN LLCFACILITY NUMBER:
079201513
ADMINISTRATOR/
DIRECTOR:		GRIMESEY,RICHARDFACILITY TYPE:
740
ADDRESS:2967 HONOR WAYTELEPHONE:
(510) 224-7357
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 6CENSUS: 6DATE:
05/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Mary Grace Abaniel, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 05/13/2026 at 11:15am, Licensing Program Analyst LPA L. Hall conducted an unannounced annual required inspection. LPA met with Caregiver, Mary Grace Abaniel, Caregiver. House Manager, Bryan Bautista, arrived at 11:30am, and explained the reason for the visit. The administrator currently holds a certificate (#7031852740) that expires on 09/25/2027. The facility’s fire clearance was approved for six (6) Non-ambulatory residents. Hospice waiver for six (6).

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of seven (7) bedrooms and three and one-half (3-1/2) bathrooms. One (1) bedroom is occupied by staff. No bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. A comfortable temperature is maintained at 71 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 120.2 degrees Fahrenheit. Night lights are maintained in hallways and passages. Residents’ bathrooms are equipped with

Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE HAVEN ROSE GARDEN LLC
FACILITY NUMBER: 079201513
VISIT DATE: 05/13/2026
NARRATIVE
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Continued from LIC809C.

grab bars and non-slip mats.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/06/2026. Emergency Disaster Plan was last reviewed on 04/11/2025. Fire drill was last conducted on 05/07/2026. First aid kit was observed to be complete.

The following forms to be updated and submitted to CCLD by 05/20/2026:
  • LIC610E Emergency Disaster Plan (last page)
  • Liability Insurance
  • LIC308 Designation of facility responsibility
  • LIC500 Personnel record
  • A copy of the administrator certificate.


LPAs observed the following deficiencies:
  • At 11:20am, LPA observed pills sitting in a cup on top of the microwave in the kitchen.
  • At 11:50am, LPA observed during record review no hospice care plan for R6.
  • At 12:00pm, LPA observed S5 has not been fingerprinted and have been working and on the schedule since 5/3/2026.


Continued on LIC809C.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SAFE HAVEN ROSE GARDEN LLC
FACILITY NUMBER: 079201513
VISIT DATE: 05/13/2026
NARRATIVE
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Continued from LIC809C.
  • At 12:05pm, LPA observed S4 and S5, did not have a file available for review.
  • At 12:20pm, LPA observed CCLD did not received a hospice initiation for R6.
  • At 12:40pm, LPA observed a lock on outside of bedroom #3 (Staff stated it is used at night.
  • At 12:44pm, LPA observed R4 had a full bedrail.
  • At 12:57pm, LPA observed a lock on the outside of bedroom #5 (Staff stated it is used at night)
  • At 12:50pm, LPA observed closet in bedroom #5 is used for a storage for facility items.

*An immediate civil penalty for $500.00 will be assessed on today's date for fingerprints*

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, LIC421BG, and this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: Laura Hall
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 03:59 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2026 at 02:58 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 ROSE GARDEN LLC
FACILITY NUMBER: 079201513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S3 and S5 available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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House Manager agreed to complete files and submit self-cetification to CCLD by POC date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and interview, the licensee did not comply with the section cited above in R4 having a full bed rail which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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House Manager agreed to have full bed rail changed to half-rail and submit photo to CCLD 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 03:59 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2026 at 02:58 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 ROSE GARDEN LLC
FACILITY NUMBER: 079201513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having a hospice care plan for R6 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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House Manager agreed to obtain a copy of the hospice care plan for R6 and submit a copy to CCLD by POC date.
Type B
Section Cited
CCR
87307(a)(2)(C)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in bedroom #5 as a passageway to storage closet for facility which poses a potential personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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House Manager agreed to remove all items from closet and submit photo to CCLD 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 03:59 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2026 at 03:14 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 ROSE GARDEN LLC
FACILITY NUMBER: 079201513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
h) The following requirements shall apply to medications which are centrally stored:

(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having pills in cup sitting on microwave in kitchen which poses an immediate health and safety risk to persons in care..
POC Due Date: 05/14/2026
Plan of Correction
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Caregiver locked pills away immediately during inspection. Deficiency cleared during inspection.
Type A
Section Cited
CCR
87355(d)
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S5 fingerprinted and associated before working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2026
Plan of Correction
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House Manager agreed to get S5 fingerprinted and submit documentation to CCLD 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2026 03:59 PM - It Cannot Be Edited


Created By: Laura Hall On 05/13/2026 at 03:24 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 ROSE GARDEN LLC
FACILITY NUMBER: 079201513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(d)(2)
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements:

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in submitting an initiation to hospice services to CCLD which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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House Manager agreed to submit a hospice notification for R6 to CCLD by POC date.
Type B
Section Cited
CCR
87468.1(a)(6)
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in having locks on the outside of doors for R2 and R5 which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 05/20/2026
Plan of Correction
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2
3
4
House Manager agreed to remove locks and submit a photo to CCLD 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.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
Laura Hall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2026


LIC809 (FAS) - (06/04)
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