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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701437
Report Date: 07/18/2024
Date Signed: 07/18/2024 01:28:35 PM

Document Has Been Signed on 07/18/2024 01:28 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 MODESTO LLCFACILITY NUMBER:
502701437
ADMINISTRATOR/
DIRECTOR:
GRIMESEY AILEENFACILITY TYPE:
740
ADDRESS:524 E UNION AVENUETELEPHONE:
(510) 224-6165
CITY:MODESTOSTATE: CAZIP CODE:
95356
CAPACITY: 6CENSUS: 5DATE:
07/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Maria Acedo and Aileen GrimeseyTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 7/18/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a pre-licensing inspection related to a change in ownership. LPA Jensen met with current Licensee Maria Acedo and applicant Aileen Grimesey,

LPA Jensen toured the grounds and observed all paths to be free of obstruction. There is patio furniture and shaded areas available for client use. All window screens were observed to be in good repair. There are no bodies of water on the premises. There is a shed on site for storage purposes that remains locked. Exits are clearly marked. LPA Jensen toured the interior. The facility was observed to be sanitary and free of odor. All furniture was observed to be in good repair, All medications, toxins and sharp objects were observed to be locked and inaccessible to residents in care. The first aid kit was complete. There is a generator on site in the event of a power outage. There is emergency lighting available. The disaster plan was reviewed and is compliant. The smoke detector and carbon monoxide detectors were tested and found to be in good working order. The water temperature was measured at 109 degrees Fahrenheit which falls within the required range of 105-120 degrees Fahrenheit. The facility maintains an adequate supply of linens. A 2 day supply of perishable food and a 7 day supply of non-perishable food was observed. The bathrooms are equipped with grab bars and non-slip flooring. There are night lights in the hallways. All resident bedrooms have dressers, lamps, night stands and chairs. All required postings were observed. The facility was observed to be in substantial compliance. 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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