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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701437
Report Date: 02/06/2025
Date Signed: 02/06/2025 11:21:15 AM

Document Has Been Signed on 02/06/2025 11:21 AM - 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:
02/06/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Ganie Avena, CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 02/06/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct a Post-Licensing. LPA Campbell met with Ganie Avena, Caregiver and explained the purpose of the visit. The facility is a one story building that is approved for residents age 60 and over with dementia. Six nonambulatory residents and/or 6 hospice residents may reside in rooms 1, 2, 3, and 4.

Upon entry, LPA Campbell observed 2 residents sitting at the dining room table and 1 resident sitting in the living room watching TV. LPA Campbell greeted the residents and inquired if they had enjoyed breakfast. All present residents stated yes and that they had just finished it. The administrator certificate was displayed in the hall entrance for Aileen Poquiz (#6060598740) and it expires on 02/14/2025. The facility license was also displayed in the hallway as well. A 'See Some Say Something" poster was in the hallway leading to client rooms. LPA Campbell observed an odor as one of the staff changed a client. The rest of the facility was odor free. The facility temperature was 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. Water temperature in one of the two bathrooms was measured at 119 degrees Fahrenheit (F). Caregiver Avena conducted a test for the carbon monoxide alarm and the smoke alarm. Both items were found to be functioning.

Upon inspection of the kitchen, a 2 day supply of perishable foods were observed in the refrigerator and more than 7 days of non-perishable foods were stored in the cabinets. The freezer temperature was -1 degrees F and the refrigerator was 38 degrees F. LPA Campbell observed a weekly menu and activity schedule affixed to the side of the refrigerator. Per staff, there are currently 5 residents and 4 staff working in the facility. LPA Campbell reviewed all residents files for completeness. One additional resident may be admitted to the facility soon.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited.
An exit interview was conducted with Ganie Avena, Caregiver and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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