502701433-8-13-2025-27-AS-ELIM-DKJ7F8-20250813213707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701433
Report Date: 08/13/2025
Date Signed: 08/13/2025 09:40:10 PM

Document Has Been Signed on 08/13/2025 09:40 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 LLC		FACILITY NUMBER:	502701433
ADMINISTRATOR/ DIRECTOR:	GRIMESEY, AILEEN POQUIZ		FACILITY TYPE:	740
ADDRESS:	2912 WESTPORT CIRCLE		TELEPHONE:	(510) 224-6165
CITY:	OAKDALE	STATE: CA	ZIP CODE:	95361
CAPACITY: 6		CENSUS:	DATE:	08/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Merlene Avena, designated facility representative		TIME VISIT/ INSPECTION COMPLETED:	03:30 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	At 9:45 AM on 8/13/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by a caregiver. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The LPA spoke with the DFA on the phone. The DFA authorized her representative, designated on the LIC308, to assist and accompany the LPA on a tour of the facility and records review. The designated representative arrived at the facility at 10:30 AM. This facility is licensed to serve six non-ambulatory residents. It has a hospice waiver for six residents. Its fire clearance was issued by Oakdale Fire Department Station 27 on 04/10/2024. The census was four residents at the time of this inspection. There was one caregiver on duty. The LPA toured the inside of the house, including four resident bedrooms, the kitchen, two bathrooms, dining room, living room, and garage. The entire house was clean, odor-free, and pest-free. The windows and window screens were in good repair. The required documents were posted in the entry way, including the license, current administrator certificate, personal rights, complaint hotline poster, and ombudsman information. The LPA inspected three smoke detectors, a carbon monoxide detector, and fire extinguisher. The smoke detectors were in the bedroom hallways and were an interconnected system. Staff tested one smoke detector and all three detectors sounded an alarm. Staff tested the carbon monoxide detector and it sounded an alarm. The fire extinguisher was last serviced on 3/28/2025 by Assured Fire Extinguisher Service. The LPA observed documentation of quarterly disaster drills. This report continues on LIC809-C, page 2.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFE HAVEN OAKDALE LLC	FACILITY NUMBER: 502701433
	VISIT DATE: 08/13/2025

NARRATIVE

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Each bedroom contained the required furniture, including bed, bedside table, lamp, dresser, and chair. The bedrooms and their closets were clean, organized, and odor-free. The bedroom hallway had a nightlight and contained storage cabinets with extra linens. One bedroom contained a full bathroom. A second bathroom was located in the bedroom hallway. Both bathrooms contained grab bars and non-slip mats. Both bathrooms were clean and odor-free. The LPA measured the water temperature at a bathroom sink, which was 113 degrees Fahrenheit.

The LPA toured the kitchen. The kitchen was clean, the appliances were operable, and the trashcan had a lid on it. There was a seven-day non-perishable and two-day perishable supply of food located in the kitchen refrigerator-freezer, cabinets, and pantry. Sharp objects were kept locked in a lower kitchen cabinet. The LPA observed chemical cleaners in an unlocked lower cabinet under the kitchen sink. Staff stated that the lock was broken. Staff immediately moved the chemicals to a locked staff office.

The LPA toured the dining room and living room, which contained enough furniture for all residents, including a dining table and chairs and six recliners. There is artwork on the walls and large windows that let in natural light.

The LPA toured the garage. The garage contained an extra refrigerator-freezer, water heater, washing machine and dryer, and storage cabinets. The LPA observed additional perishable food in the refrigerator-freezer and extra supplies for residents in the storage cabinets. The LPA observed chemical cleaners in an unlocked storage cabinet in the garage. Staff immediately locked the access door that led from the house to the garage with a key that only staff had.

The LPA toured the back yard, which included a large, wooden shade structure with a table and chairs under it. The concrete patio and walkways on the side of the house are free of obstructions and the surrounding fence is intact and sturdy.

This report continues on LIC809-C, page 3.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SAFE HAVEN OAKDALE LLC	FACILITY NUMBER: 502701433
	VISIT DATE: 08/13/2025

NARRATIVE

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The LPA inspected the central medication storage area. Residents’ medication was kept in a locked cabinet in the kitchen. Each resident’s medication was stored separately in its original containers with intact labels. The LPA observed the electronic-based medication administration record, which was complete and up-to-date. There was a first aid kit in the medication cabinet that contained all the required items.

The LPA reviewed records for four residents and two staff and found the records to be complete. Both staff had criminal background clearances and current first aid/CPR certifications. The Administrator’s certificate was valid (#7026256740) and expires 2/14/2027.

The LPA requested that updated copies of these documents be submitted to Licensing by 8/27/2025 at ellen.lindstrom@dss.ca.gov.

(1) LIC 308 Designation of Facility Responsibility
(2) Copy of a current Administrator Certificate
(3) LIC 610 Emergency Disaster Plan
(4) Proof of Liability Insurance
(5) LIC 500 Personnel Report
(6) LIC 309 Administrative Organization

As a result of this annual visit, one deficiency was cited (see LIC809-D). The facility was not in compliance
with Title 22 Regulation. An exit interview was conducted with the designated staff and a copy of the LIC 809,
LIC 809-D, and appeal rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/13/2025 09:40 PM - It Cannot Be Edited

Created By: Ellen Lindstrom On 08/13/2025 at 03:04 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: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not comply with the section cited above, as staff left chemical disinfectants in storage cabinets with broken locks in the kitchen and garage, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2025
	Plan of Correction
1 2 3 4	Staff immediately transferred the chemicals under the kitchen sink to a locked office and locked the door to the garage with a key. The Administrator scheduled a handyman to fix the locks tomorrow. Administrator will send LPA LIndstrom a statement that the locks have been fixed, a copy of the invoice for the work performed, and a picture of the new locks.

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.

	Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:

	Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025

LIC809 (FAS) - (06/04)

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