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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208898
Report Date: 01/29/2025
Date Signed: 01/29/2025 07:57:04 PM

Document Has Been Signed on 01/29/2025 07:57 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/
DIRECTOR:		SOTO, VERONICAFACILITY TYPE:
735
ADDRESS:39874 ROAD 16TELEPHONE:
(559) 380-8549
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY: 6CENSUS: 4DATE:
01/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:House Manager, Rachel BybeeTIME VISIT/
INSPECTION COMPLETED:
08:05 PM
NARRATIVE
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On 1/29/25 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA was met by House Manager, Rachel Bybee, explained reason for visit and was permitted entry into the facility. Administrator, Veronica Soto was contacted and gave permission to complete visit with House Manager. Clients not present during visit.

LPA toured the facility inside and out. 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 2/26/24. Last fire drill on 12/9/23. Water temperature measured degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets in hallways. Medications were located in locked cabinet off kitchen. LPA observed sufficient seating under covered patio areas.

The following issues were observed during todays visit: Walls in hallways and door frames in need of repair and touch up paint. Carpet in den in need of re-tacking/transition. Master bathroom drawers broken and in need of repair. Linen closet door knob missing and in need of repair. Bathroom #2 observed with towel rack broken and in need of removal/repair. Bedroom #4 observed with mattress in disrepair and in need of replacement. Light in guest bathroom observed without cover. Broken drawer observed in kitchen in need of repair. Pool fence in need of repair. Walkway to left of facility observed with moss on sidewalk in need of cleaning. Garage lodge observed with hole in dry wall in need of repair. Debris observed in garage lodge in need of removal. Chemicals observed under master bathroom sink unlocked and accessible.
CONT...
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 4
Document Has Been Signed on 01/29/2025 07:57 PM - It Cannot Be Edited


Created By: Mary Garza On 01/29/2025 at 07:13 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAFE HARBOR HOMES AND SERVICES
FACILITY NUMBER: 107208898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that Walls in hallways and door frames in need of repair and touch up paint. Carpet in den in need of retacking/transition. Master bathroom drawers broken and in need of repair. Linen closet door knob missing and in need of repair. Bathroom #2 observed with towel rack broken and in need of removal/repair. Light in guest bathroom observed without cover. Broken drawer observed in kitchen in need of repair. Pool fence in need of repair. Walkway to left of facility observed with moss on sidewalk in need of cleaning. Garage lodge observed with hole in drywall in need of repair. Debris observed in garage lodge in need of removal. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator stated items will be corrected by POC date. Pictures will be sent to CCL as proof of corrections.
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that chemicals observed under master bathroom sink unlocked and accessible. Chemicals observed in guest bathroom cabinet unlocked and accessible. Chemicals observed in stair closet unlocked and accessible. Chemicals observed in garage lodge unlocked and accessible. Razors under master bathroom sink unlocked and accessible. Tools observed in green house unlocked and accessible. Wood chipper observed in the garage lodge unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Administrator stated they will provide all staff training to staff on regulation. Training material and in-service sign in sheet will be provided to CCL by POC date as proof of correction.
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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/29/2025 07:57 PM - It Cannot Be Edited


Created By: Mary Garza On 01/29/2025 at 07:13 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SAFE HARBOR HOMES AND SERVICES
FACILITY NUMBER: 107208898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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Based on LPA review of records, the licensee did not comply with the section cited above in that the facility does not have the updated Disaster Plan completed. Facility was observed to have outdated form being used. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator stated they will update form and provide to CCL by POC date.
Type B
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in Facility has not completed quarterly drills during 2024. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Admniistrator stated they will preform a drill by POC date and submit documentation to CCL by POC 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.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SERVICES
FACILITY NUMBER: 107208898
VISIT DATE: 01/29/2025
NARRATIVE
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CONT...

Chemicals observed in guest bathroom cabinet unlocked and accessible. Chemicals observed in stair closet unlocked and accessible. Chemicals observed in garage lodge unlocked and accessible. Razors under master bathroom sink unlocked and accessible. Tools observed in green house unlocked and accessible. Wood chipper observed in the garage lodge unlocked and accessible. Mattress was observed sagging in middle. Facility to provide resident with a new mattress in good repair. Facility has a copy of the Disaster Plan however, it is on the wrong form and needs to be update. Administrator will update and submit to CCL with annual documentation. Assembly points not on facility sketch. Facility has not completed quarterly drills during 2024.

LPA requested the following documents to be submitted to CCL by 2/7/25: 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.

Exit interview completed with Administrator, Veronica. A copy of this report, deficiencies, TV's and appeal rights were provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4