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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700469
Report Date: 10/22/2025
Date Signed: 10/22/2025 05:01:36 PM

Document Has Been Signed on 10/22/2025 05:01 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GREAT HAVENFACILITY NUMBER:
342700469
ADMINISTRATOR/
DIRECTOR:		EZE, CHINYEREFACILITY TYPE:
740
ADDRESS:71 GROTH CIRTELEPHONE:
(916) 833-6388
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 6CENSUS: 6DATE:
10/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Gift EzeTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On October 22, 2025, Licensing Program Manager (LPM) Troy Ordonez and Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to discuss the current status of the licensed entity and the next steps required to bring the facility into compliance. LPM and LPA met with Administrator and explained the purpose of the visit.

It was learned that Great Haven LLC, licensed to operate a Residential Care Facility for the Elderly (RCFE), was terminated/dissolved with the California Secretary of State on 09/30/2021. The LLC previously had two managing members, each holding equal ownership. One member walked away without submitting a formal withdrawal or resignation to Community Care Licensing (CCL). The remaining member expressed interest in forming a new LLC and continuing operations

LPA Yang discussed that once an LLC is terminated, it is no longer recognized by the Secretary of State and cannot legally conduct business or hold a care license in the State of California. Because the RCFE license was issued under the terminated LLC, the license is considered forfeited and no longer valid.

Today's visit, Administrator was able to provide LPA proof of control of property. Licensee was instructed to draft a new lease to the new LLC for the change of ownership application.

Continue LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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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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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GREAT HAVEN
FACILITY NUMBER: 342700469
VISIT DATE: 10/22/2025
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LIC 809-C

In order to move forward, the following steps must be completed:

· Form a new LLC or business entity to assume operational responsibility for the facility.

· Secure a new lease agreement under the new entity or individual licensee by close of business (COB) October 23, 2025.

· Submit a complete Change of Ownership (CHOW) application to Community Care Licensing (CCL) by COB October 24, 2025.

· Submit all notifications for the residents, and their responsible parties, in regard to the change of ownership into CCL by COB October 24, 2025



· Secure a new lease agreement immediately, under the newly formed LLC. Submit a Change of Ownership (CHOW) application with Community Care Licensing (CCL) to transition the RCFE license to the new entity.

LPA advised that operations cannot continue under the terminated LLC or forfeited license. Compliance with the above steps is required before any new license can be approved or care operations resumed.

At this time, Administrator was instructed to refrain from accepting new residents until the change of ownership.

No deficiencies cited.

Exit interview conducted, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Cassie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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