<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200781
Report Date: 05/29/2026
Date Signed: 05/29/2026 05:51:35 PM

Document Has Been Signed on 05/29/2026 05:51 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:NEW HAVENFACILITY NUMBER:
079200781
ADMINISTRATOR/
DIRECTOR:		ELIZABETH CORTES- PALADFACILITY TYPE:
740
ADDRESS:2236 WHYTE PARK AVENUETELEPHONE:
(510) 965-5555
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY: 6CENSUS: 6DATE:
05/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver Marilou LadabanTIME VISIT/
INSPECTION COMPLETED:
06:00 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
On 05/29/2026, at 09:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this Required Annual inspection. Upon entry, the LPA stated the purpose of the visit to Caregiver Marilou Ladaban..

The LPA toured the facility, including but not limited to residents’ rooms, bathrooms, kitchen, common areas, and the yard. The LPA observed adequate lighting for the comfort and safety of residents in all rooms. The walkways in both the interior and exterior of the facility are free from obstructions. There are no bodies of water. The temperature of the refrigerators was below 40 degrees Fahrenheit and the freezers below 0 degrees Fahrenheit. At 10:58 AM, the dining room temperature was measured; it was 72.1 degrees Fahrenheit. At 11:13 AM, the maximum hot water temperature was measured in the kitchen; it was 113.9 degrees Fahrenheit.

The residents’ bathrooms are equipped with grab bars and slip-resistant mats. There is more than a 7-day supply minimum of nonperishable foods and a 2-day of perishable foods. The LPA observed the required postings in the facility, except for the 20" x 26" Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475). Smoke detectors and carbon monoxide detectors were tested and found to be in operating condition. The fire extinguisher was fully charged and last replaced on 06/22/2025. The Emergency Disaster Plan was reviewed within the past year; the most recent review was on 01/09/2026. No record of emergency, disaster, and fire drills being conducted on a quarterly basis. First aid kit was observed to be complete. Liability insurance expires on 02/02/2027.

Continued on LIC 809-C . . .
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781
VISIT DATE: 05/29/2026
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
26
27
28
29
30
31
32
. . . Continued from LIC 809

The LPA reviewed 5 Resident, 4 Staff, and Facility records.

The following citations were issued during the inspection:
  • Personnel Records/Staff Training - Type B: Title 22 87412(f) - no administrator records at facility
  • Personnel Records/Staff Training - Type B: HSC 1569.625(b)(2) - inadequate proof that 4 of 4 staff completed all 20 hours of training
  • Disaster Preparedness - Type B: HSC 1569.695(c) - no written proof of quarterly drills

A total of three (3) citations (3 Type B) were issued for deficiencies during this inspection.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 809-D. Failure to submit Proof of Corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Harpreet Humpal
NAME OF LICENSING PROGRAM ANALYST: James Sampair
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/29/2026 05:51 PM - It Cannot Be Edited


Created By: James Sampair On 05/29/2026 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of five staff files, because there is no file with the Administrator certificate or any other required document, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
1
2
3
4
On or before the due date, the Administrator shall create and store at the facility a complete file with her Administrator certificate and all of the other required documents in it. On or before the due date, the Administrator shall inform LPA Sampair of the completion of this task.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 of 4 staff files. There was inadequate proof that 4 of 4 staff completed of the required 20 hours of training, which posesd a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall provide proof of the training that was completed within the last year. For all of those staff members who have not completed the 20 hours of training, they shall complete it on or before the due date. The Licensee shall inform LPA Sampair of the completion on or before the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/29/2026 05:51 PM - It Cannot Be Edited


Created By: James Sampair On 05/29/2026 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW HAVEN
FACILITY NUMBER: 079200781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 of the 4 quarters during the past year because they had no recorded proof of having conducted quarterly drills, which poses a potential safety risk to persons in care.
POC Due Date: 06/05/2026
Plan of Correction
1
2
3
4
On or before the due date, the Licensee shall: print the emergency drill log, add the most recent drill to the log, and add it and additional copies of the log for future years into facility binder.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet Humpal
NAME OF LICENSING PROGRAM MANAGER:
James Sampair
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5