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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208871
Report Date: 08/19/2023
Date Signed: 09/05/2023 09:03:35 AM

Document Has Been Signed on 09/05/2023 09:03 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAFE HAVEN COMMUNITY CARE HOMES INCFACILITY NUMBER:
107208871
ADMINISTRATOR:SINGH, BHAGATVEERFACILITY TYPE:
735
ADDRESS:5365 E PITT AVETELEPHONE:
(559) 492-3128
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 4CENSUS: 3DATE:
08/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH: Licensee, Singh BhagatveerTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Singh Bhagatveer, Continual Administrator's Certification expires 10/20/204. There are currently 3 residents who reside at this home at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 110 degrees. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt confirmed all staff present is background cleared.

The facility does not have documented quarterly disaster drills. The facility does not have an updated Emergency Disaster Plan. The facility is not correctly documenting residents Centrally Stored Medications. The facility window screens are torn and several are missing.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610 the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Singh Bhagatveer, and copy of report left at facility
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2023
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 2
Document Has Been Signed on 09/05/2023 09:03 AM - It Cannot Be Edited


Created By: Sarah Hurt On 08/19/2023 at 03:36 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
,
, CA

FACILITY NAME: SAFE HAVEN COMMUNITY CARE HOMES INC
FACILITY NUMBER: 107208871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above in LPA Hurt reviewed facility centrally stored logs for Resident 1, and Resident 2, and medications were not correctly documented on the Centrally Stored logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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LIcensee agrees to provide Centrally stored logs for residents by POC date of 08/31/23.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in LPA Hurt was not provided with the requested emergency disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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Licensee will provide Emergency disaster plan to LPA Hurt by 08/31/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Sarah Hurt
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2023


LIC809 (FAS) - (06/04)
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