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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603048
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:35:32 PM

Document Has Been Signed on 06/08/2022 03:35 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAFE HAVENFACILITY NUMBER:
198603048
ADMINISTRATOR:WENDY MULLENFACILITY TYPE:
772
ADDRESS:12580 LAKELAND AVETELEPHONE:
(562) 906-2686
CITY:SANTA FE SPRINGSSTATE: CAZIP CODE:
90670
CAPACITY: 16CENSUS: 4DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Luis Rodriguez - Program AssistantTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food supplies. LPA Mora met with Program Assistant Luis Rodriguez and Psychiatric Social Worker Miguel Garcia and explained the reason for the visit.

The facility is a Social Rehabilitation Facility licensed to serve 16 ambulatory only clients. This facility is considered a short-term crisis residential treatment program. The program consists of 1 large single-story building. A tour of the single-story building included: reception area, group room, waiting room, 5 offices, 8 client bedrooms, 3 client bathrooms, 1 medication room, kitchen, dining room, outside patio, and outside storage shed.

LPA toured the facility with Luis Rodriguez and Miguel Garcia and the following was observed: a total of 4 clients were at the facility during the visit. The staff to client ratio is 1:3. The program site is clean, safe, sanitary and in good repair. All passageways are free from obstruction. Disinfectants, cleaning solutions and poisons are inaccessible to clients and are locked inside a kitchen cabinet. There are 5 fire extinguishers in total throughout the facility. All the fire extinguishers are fully charged. Facility has a wired fire system throughout the facility. There are multiple carbon monoxides throughout the facility. The bathrooms were observed to be clean and showers have a no-skid mat. The water temperature was tested in all bathrooms and it measured between at 109 degrees F and 114 degrees F, which is within the required 105-120 degrees F. The program maintains a comfortable temperature in each room/office. The First Aid kit is kept in the kitchen and it is fully stocked with all required items including a current manual. Sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps are kept locked in administrator offices. The last fire/emergency disaster and earthquake drills were conducted on 03/29/2022. LPA reviewed 4 client files and observed no issues. LPA reviewed 3 staff records and observed no issues.

(CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAFE HAVEN
FACILITY NUMBER: 198603048
VISIT DATE: 06/08/2022
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Facility has 30 days supplies of Personal Protective Equipment in the outside storage shed. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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