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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208898
Report Date: 10/04/2021
Date Signed: 10/04/2021 02:26:18 PM

Document Has Been Signed on 10/04/2021 02:26 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SAFE HARBOR HOMES AND SERVICESFACILITY NUMBER:
107208898
ADMINISTRATOR:SOTO, VERONICAFACILITY TYPE:
735
ADDRESS:39874 ROAD 16TELEPHONE:
(559) 380-8549
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY: 6CENSUS: 3DATE:
10/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Veronica SotoTIME COMPLETED:
12:58 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
Licensing Program Analyst (LPA) L. Xiong conducted a case management visit for the purpose of Health and Safety check of Residents in care due to a complaint that came into our office on 10/01/21. I met with Administrator, Veronica Soto and informed her the purpose of the visit.

Currently, 3 residents living in the facility.

A tour of the facility was conducted. Facility observed to be clean and odor free. Facility temperature comfortable. LPA measured water temperature 105 degrees F. Adequate food supply to meet the needs of residents. Fire Extinguisher current and smoke detectors observed operational during today's visit. LPA observed cleaning supplies and medications locked and inaccessible to residents.

LPA observed residents in the dining/kitchen area with staff.

No deficiencies observed during this visit.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2021
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 1