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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208898
Report Date: 01/17/2024
Date Signed: 01/17/2024 05:12:52 PM

Document Has Been Signed on 01/17/2024 05:12 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
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: 5DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Administrator, Veronica SotoTIME COMPLETED:
05:25 PM
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On 1/17/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by Administrator, Veronica Soto. LPA introduced self, explained reason for visit and was permitted entry into the facility.

LPA completed a health and safety check on residents in care. LPA toured the facility inside and out. 1 residents at home during time of inspection. 4 residents in program per Administrator. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 02/20/2023. Last fire drill on 12/9/23. Water temperature measured 119.2 degrees. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps locked in a locked drawer and medications were located in locked cabinet off kitchen. LPA observed sufficient seating under covered patio areas.

During visit the following issues were observed: Debris behind hot house, chemical and tools in hot house, debris in area past chicken coop, tools and chemicals observed in 5 car garage, pruning sheers observed in house garage on shelf and laundry room chemical closet lock broken and accessible to residents in care, garage refrigerator in need of being wiped down.

LPA requested the following documents to be submitted to CCL by: 1/26/24 current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

No deficiencies were cited during the inspection. TA's provided on the above listed issues. Due to time constraints, LPA will return at a later date for an annual continuation. Exit interview completed with Administrator, Veronica Soto. A copy of this report was given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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