<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435601018
Report Date: 10/28/2024
Date Signed: 10/28/2024 07:22:20 PM

Document Has Been Signed on 10/28/2024 07:22 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SAFE HAVEN VILLA CARE HOMEFACILITY NUMBER:
435601018
ADMINISTRATOR/
DIRECTOR:		THELMA LLANESFACILITY TYPE:
740
ADDRESS:5670 JUDITH STREETTELEPHONE:
(408) 809-4131
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and was greeted by the staff Amelia Obra. The licensee/administrator (LIC/ADM) Thelma Llanes was not present at the time of the visit. Per staff, ADM was in attending an in-service training at the hospital where she works as an on-call staff. ADM arrive at the facility at 5:20 p.m.

The facility is licensed to serve adults 60 and over, approved for 6 non-ambulatory and waiver for 2 hospice and 1 bedridden allowed. LPA observed 4 residents present at the facility that have neurocognitive disorder, 1 staff (S1) present and the owner's spouse (S2) who has been in the facility since 7/16/2024 after retirement and does not have a criminal record clearance on record. S2 stated that he helps cleans, cook and maintain the facility. S2 stated he/she does not give direct care to the residents.

At 3:35 p.m. LPA toured the facility inside and outside with S1 including but not limited to the kitchen, bathroom, dining room, living room, 4 residents rooms, garage, staff room, backyard and exterior walkways.
The facility is maintained, sanitary and organized. The bathroom/s are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured between 128.6 degree Fahrenheit. Resident's room have sufficient storage. The temperature inside the home was at 73 degrees Fahrenheit.

The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. The kitchen water temperature measured at 128.8 degrees Fahrenheit.


page 1 of 2, see LIC 809C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SAFE HAVEN VILLA CARE HOME
FACILITY NUMBER: 435601018
VISIT DATE: 10/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff.

The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer is located in the garage and is in good working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care.

The facility is equipped with a fire, smoke and carbon monoxide alert system, night lights on the hallway are in good working condition. The hallway are free from obstruction. LPA observed 3 surveillance cameras inside the facility on the hallway and kitchen. The video is not recording and there is no audio.

LPA reviewed 2 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening. LPA reviewed 1 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. Staff have criminal record clearance/fingerprints.

LPA gave technical advisory to ADM for records keeping and maintenance of information and warning signs for taps delivering water at 125 degree Fahrenheit and above. ADM stated that he/she has the documents and will complete the files of each resident and staff.

Deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22 87355 (e) and 87303 (e)(2), see LIC 809D.

An exit interview was conducted with administrator Thelma Llanes. A copy of the report and appeals rights were provided.

page 2 of 2
end of report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/28/2024 07:22 PM - It Cannot Be Edited


Created By: Maria Partoza On 10/28/2024 at 06:06 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAFE HAVEN VILLA CARE HOME
FACILITY NUMBER: 435601018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in by not maintaining the hot water temperature at 105 degree F to 120 F. LPA measured the water temperature in the resident's bathroom with a digital thermometer witnessed by S1. Water temperature measured at 128.6 degree Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
ADM adjusted the water temperature while LPA was in the facility. ADM stated that the water temperature is set between 105 to 120. ADM will submit a written plan of action on how the facility will ensure that the water temperature is regulated at 105 to 120 degree F by the due date.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview the licensee did not comply with the section cited above by not having S2 (spouse) acquire a criminal background clearance prior to residing at the facility. S2 stated the he/she recently retired from the military service and have resided at the facility when he/she retired and did not have a live scan when asked by LPA, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
1
2
3
4
ADM sent S2 to obtain a livescan while LPA was at the facility. ADM stated that S2 will not be at the facility until live scan has cleared and S2 is associated to the facility. ADM will submit a plan of correction on how the facility will ensure that all individuals prio to residing, volunteering or working at the facility will be have criminal background clearance by the due 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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/28/2024 07:22 PM - It Cannot Be Edited


Created By: Maria Partoza On 10/28/2024 at 06:07 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SAFE HAVEN VILLA CARE HOME
FACILITY NUMBER: 435601018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having disaster plan training, and emergency plan in place which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
1
2
3
4
ADM stated that training was provided a year ago and have not done one in a while. ADM will submit a written plan of correction on how the facility will conduct disaster training and have an emergency plan in place by the correction due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4