502701437-8-8-2025-27-AS-ELIM-DKCVFT-20250808162427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 502701437
Report Date: 08/08/2025
Date Signed: 08/08/2025 04:24:36 PM

Document Has Been Signed on 08/08/2025 04:24 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 MODESTO LLC		FACILITY NUMBER:	502701437
ADMINISTRATOR/ DIRECTOR:	GRIMESEY AILEEN		FACILITY TYPE:	740
ADDRESS:	524 E UNION AVENUE		TELEPHONE:	(510) 224-6165
CITY:	MODESTO	STATE: CA	ZIP CODE:	95356
CAPACITY: 6		CENSUS:	DATE:	08/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:26 PM
MET WITH:	.,m		TIME VISIT/ INSPECTION COMPLETED:	04:24 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 1:30 PM on 08/08/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to conduct a required annual inspection. LPA Lindstrom was greeted by two staff members. The LPA identified herself, explained the purpose of the visit, and asked to meet with the Administrator. Staff called the Administrator, who authorized her on-duty staff with designated facility responsibility to accompany the LPA on a tour of the facility. The CARE inspection tool was used during this inspection. At the time of this inspection, the Administrator had a valid Administrator Certificate (#7026256740), which expires on 2/14/2027. Both staff on duty at the time of this visit had criminal background clearances. The facility is a four-bedroom, single-story house in a residential neighborhood. The facility is licensed to serve 6 residents. At the time of this inspection, the facility census was four, although the capacity was six. The LPA began the tour in the front yard. The front yard has bushes, trees, and rock xeriscape. The LPA entered the facility through the front door and observed that it was clean, decorated, odor-free, and full of natural light. The LPA toured the common areas including the living room, dining room, and family room. The LPA observed a resident in the living room watching television. The living room contained a couch, a rocking chair, and three chairs with footrests. A dining room table with chairs separated the living room from the kitchen. A fire extinguisher hung from the wall that was last serviced by A.R.F. Fire Extinguisher Co. on February 2025. There was an extra family room with additional seating and a television off the kitchen.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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 MODESTO LLC	FACILITY NUMBER: 502701437
	VISIT DATE: 08/08/2025

NARRATIVE

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The LPA toured the kitchen. The kitchen was clean and sanitary. The LPA observed a seven-day supply of non-perishable food and two-day supply of perishable food in the kitchen cabinets, pantry, and refrigerator/freezer. There were enough utensils and dishware for all residents. The trash can had a lid on it. Sharps were locked in an upper cabinet and chemicals were locked in the cabinet under the kitchen sink. The LPA observed the required postings on the wall, including the license, Administrator’s Certificate, Complaint Hotline poster, fire clearance, licensing reports, and Facility Sketch.

The LPA toured the four bedrooms. The LPA observed that all the bedrooms were clean, organized, and contained the required furniture. Each bedroom contained personal objects and decorations unique to its residents. The temperature on the thermostat in the bedroom hallway was 80 degrees Fahrenheit. There was a small walk-in space off this hallway that contained extra bedding and office supplies. Staff tested the carbon monoxide/smoke detector in the hallway and the alarm sounded.

The LPA inspected the locked central medication storage area, which was in a locked closet in the bedroom hallway. The LPA observed separate storage units for each resident’s medication. All medicine was in its original container with unaltered labels. The facility used a paper-based Medication Administration Record (MAR), which staff initials after assisting with each medication administration. The first aid kit stored in this closet contained all the required items.

The LPA toured two full bathrooms. The bathrooms were clean and odor free. Both bathrooms contained grab bars and non-slip surfaces. The hot water temperature measured within the required range. The facility had the water heater adjusted yesterday, which the LPA confirmed with the Administrator, and staff will monitor the water temperature to ensure it stays in compliance.

The LPA toured the garage. The LPA observed a washer, dryer, and an additional refrigerator/freezer with extra food in the garage. Staff used the garage to store resident supplies.

The LPA toured the backyard. The backyard had a decorative border of plants along the fence line. The fence surrounding the backyard was sturdy and intact, and the walkways were free from obstruction. There was a table with a shade umbrella and chairs for residents on the back patio. There was a shed in the backyard used for storage by residents and staff.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

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 MODESTO LLC	FACILITY NUMBER: 502701437
	VISIT DATE: 08/08/2025

NARRATIVE

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The LPA requested staff and resident records. The LPA inspected these records and found them complete.
The LPA requested that updated copies of the following documents be submitted to Licensing by 5:00 PM on 87/22/2025. These documents can be emailed to LPA at ellen.lindstrom@dss.ca.gov.

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

As a result of this inspection, no deficiencies were cited. The facility was in compliance with California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted with staff, to whom a copy of this LIC809 report was provided. Their signature below confirms receipt of this document.

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025

LIC809 (FAS) - (06/04)

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