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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701433
Report Date: 07/18/2024
Date Signed: 07/18/2024 01:24:40 PM

Document Has Been Signed on 07/18/2024 01:24 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SAFE HAVEN OAKDALE LLCFACILITY NUMBER:
502701433
ADMINISTRATOR/
DIRECTOR:
GRIMESEY, AILEEN POQUIZFACILITY TYPE:
740
ADDRESS:2912 WESTPORT CIRCLETELEPHONE:
(510) 224-6165
CITY:OAKDALESTATE: CAZIP CODE:
95361
CAPACITY: 6CENSUS: 4DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Aileen Grimesey and Eileen GrimesyTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 7/18/24 Licensing Program Analyst (LPA) Maja Jensen arrived at 524 E Union St in Modesto announced to continue a pre-licensing inspection related to a change in ownership. LPA Jensen met with current Licensee Maria Acedo and applicant Aileen Grimesey,

LPA Jensen received photographic evidence that the doors connecting resident rooms have been equipped with a locking mechanism to allow for passage from room to room. LPA Jensen received an updated copy of the Plan of Operation with all requested revisions made. The applicant has agreed that no surveillance cameras will be used in the interior of the facility unless a waiver is requested and approved by the Department which details a compelling health and safety reason for use.

The current owner is sending formal written notification of transfer of the business today and providing a 60 day notice. LPA Jensen reviewed the notice and determined it to be compliant. The applicant has passed the pre-licensing inspection and component III was conducted however licensure will require a 60 day waiting period so that residents or resident representatives have an adequate period of time for consideration.
An exit interview was conducted and a copy of this report was given
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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