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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208898
Report Date: 02/27/2023
Date Signed: 03/14/2023 08:44:01 AM

Document Has Been Signed on 03/14/2023 08:44 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
SIERRA CASCADE AC/SC, 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:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:House Manager, Rachel BybeeTIME COMPLETED:
03:17 PM
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On 2/27/2023 Licensing Program Analyst (LPA) M. Garza arrived at facility to complete an unannounced infection control/annual visit. LPA met with House Manager, Rachel Bybee discussed reason for visit and was permitted entry into the facility. Administrator, Veronica Soto was contacted and permission was given to complete visit with House Manager, Rachel. LPA observed sign in sheet and was COVID pre-screened at time of entry. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms at time of visit.

Required postings including coughing/sneezing etiquette and hand washing posting observed at hand washing stations and throughout the facility. Furniture in common areas are spaced to promote physical distancing. A 2-day supply of perishable and 7-day supply of non-perishable food was observed. Bedrooms observed with required furnishings and lighting. Facility telephone was observed working at time of visit A supply of PPE is located in hallway cabinet. The 30 day supply of medication is located in a locked cabinet off the kitchen.



Linens, hygiene and cleaning supplies observed.. Fire Extinguisher last serviced 02/20/23. LPA requested the following updated forms by 3/6/2023: LIC 308, LIC 309, LIC 500, LIC 610D, and LIC 9020.

No deficiencies cited during todays visit. Exit interview completed with House Manager, Rachel and Administrator, Veronica. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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