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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701433
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:03:24 PM

Document Has Been Signed on 03/11/2025 03:03 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: 6DATE:
03/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Chyl-c Anaviso, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to open a complaint investigation. During the course of that investigation, LPA Campbell discovered other deficiencies unrelated to the complaint allegations, which will be addressed in this case management report. LPA Campbell met with Caregiver, Chyl-c Anaviso and Emilie Carno, Caregiver and explained the purpose of the visit.

LPA Campbell conducted a review of resident Medication Administration Records (MAR) and observed that Staff 1(S1) had not initialed the form for medication dispersal for five days in a row. Per regulation 87465(a), the facility is to establish 'a plan for incidental medical care' to 'encourage routine medical and dental care.'

LPA Campbell observed missing staff initials for Resident 2 (R2) and R3 for five days from March 6 to March 11. When questioned, S1 admitted that they had not filled out the form as required in the plan established by the facility and they reported that they had been tired and busy with a resident.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiency is being cited on the attached 809-D during this visit. 
An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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Document Has Been Signed on 03/11/2025 03:03 PM - It Cannot Be Edited


Created By: Renee Campbell On 03/11/2025 at 01:45 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFE HAVEN OAKDALE LLC
FACILITY NUMBER: 502701433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87465(a)

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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
Based on a review of the facility
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The lincensee will establish a procedure for auditing the MAR to ensure established procedures are followed and read and present a memorandum of understanding for regulation 87465.
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medication administration record (MAR) and Controlled Medication Administration Record, it was observed that required names/initials for medication dispersal were not filled out which poses/posed an immediate risk to the health, safety, and personal rights of the residents in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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