Most inspections found no deficiencies, with the facility demonstrating readiness for licensing and compliance with safety and operational standards in September and October 2024. However, the most recent inspection on May 14, 2025, identified several deficiencies related to staff training, including missing dementia care and hospice care training, as well as incomplete documentation and missing doctor’s orders for bedrails for some residents. These issues were addressed with agreed-upon plans of correction and were considered minor without any enforcement actions or fines listed. There is a clear improvement from the initial licensing evaluations, which were clean, to the recent inspection where training gaps were noted. Several complaint investigations were not part of these reports, so no substantiated complaints were recorded.
Deficiencies per Year
43210
2024
2025
Moderate
Census Over Time
CensusCapacity
Inspection Report Original LicensingCensus: 4Capacity: 6Deficiencies: 4May 14, 2025
Visit Reason
An unannounced post licensing inspection was conducted to evaluate compliance with licensing requirements following the facility's initial licensing.
Findings
The inspection found that the facility maintained adequate safety measures and supplies, but deficiencies were noted including lack of required staff training, missing doctor's orders for bedrails for three residents, and incomplete documentation. Plans of correction were agreed upon with due dates.
Severity Breakdown
Type B: 4
Deficiencies (4)
Description
Severity
Staff members did not have required training including Dementia Care training.
Type B
Three out of four residents did not have doctor's orders for bedrails.
Type B
Staff training on postural supports, restricted conditions, and hospice care was not provided or documented.
Type B
Staff were not trained on care of persons with dementia.
Type B
Report Facts
Residents: 4Licensed capacity: 6Deficiencies cited: 4Plan of Correction due date: May 21, 2025
Employees Mentioned
Name
Title
Context
Ryan Alejo
Administrator
Facility Administrator contacted during inspection and agreed to plans of correction
Emarita Morales
Caregiver
Met with Licensing Program Analyst during inspection
Tonica Syess-Gibson
Licensing Program Analyst
Conducted the inspection and authored the report
Harpreet Humpal
Licensing Program Manager
Named as Licensing Program Manager on report
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Oct 2, 2024
Visit Reason
An announced pre-licensing inspection was conducted to evaluate the facility's readiness for licensing and compliance with applicable regulations.
Findings
No issues were noted during the inspection. The facility was found to be ready for licensing with all safety and facility requirements met, including fire clearance, proper furniture, safety equipment, and environmental conditions.
Report Facts
Fire extinguisher last serviced date: Apr 22, 2024Hot water temperature (Fahrenheit): 109.7Facility bedrooms count: 4Facility bathrooms count: 3Fire clearance capacity: 6Hospice waiver capacity: 4
Employees Mentioned
Name
Title
Context
Ryan Alejo
Administrator
Met with Licensing Program Analyst during inspection
Raman Deep
Licensee
Met with Licensing Program Analyst during inspection
Laura Hall
Licensing Program Analyst
Conducted the announced pre-licensing inspection
Harpreet Humpal
Licensing Program Manager
Gave approval to waive Comp III
Inspection Report Original LicensingCapacity: 6Deficiencies: 0Sep 13, 2024
Visit Reason
The visit was conducted as an initial licensing evaluation for the facility Safe Haven Oakley LLC to verify applicant and administrator understanding of licensing laws and readiness for operation.
Findings
The applicant and administrator successfully completed the Component II evaluation, demonstrating understanding of licensing laws, facility operation, admission policies, staffing requirements, emergency preparedness, complaints and reporting, and pre-licensing readiness.
Employees Mentioned
Name
Title
Context
Ryan Q Alejo
Administrator
Named as facility administrator and participant in licensing evaluation
Caitlin Robinson
CEO
Named as CEO and participant in licensing evaluation
Tracy Thompson
Licensing Program Manager
Named as Licensing Program Manager overseeing the evaluation
Ricmar Soriano
Licensing Program Analyst
Named as Licensing Program Analyst conducting the evaluation
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