Safe Haven Modesto

Type of visit: Required - 1 Year

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. 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. 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.the state’s words, verbatim · CDSS document, Aug 8, 2025

Type of visit: Post Licensing

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.the state’s words, verbatim · CDSS document, Feb 6, 2025

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: GRIMESEY, AILEEN - Licensee/Administrator Interview Method: Virtual interview On 06/11/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 11, 2024