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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603048
Report Date: 06/13/2023
Date Signed: 06/13/2023 02:53:07 PM

Document Has Been Signed on 06/13/2023 02:53 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SAFE HAVENFACILITY NUMBER:
198603048
ADMINISTRATOR:CARYL LARKFACILITY TYPE:
772
ADDRESS:12580 LAKELAND AVETELEPHONE:
5629062686
CITY:SANTA FE SPRINGSSTATE: CAZIP CODE:
90670
CAPACITY: 16CENSUS: 13DATE:
06/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Caryl Lark - AdministratorTIME COMPLETED:
03:07 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Garrett Silva (Mental Health Advocate) and explained the reason for the visit. Shortly after Maria Ortiz (Clinical Manager) and Caryl Lark (Administrator) arrived to take over. 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, 2 group rooms, 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 Garrett Silva and the following was observed: a total of 13 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 an office. There are 5 fire extinguishers in total throughout the facility. All the fire extinguishers are fully charged. Facility has a sprinkler fire system throughout the facility. There are carbon monoxides in each bedroom and 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 105.2 degrees F and 116.9 degrees F, which is within the required 105-120 degrees F. The program maintains a comfortable temperature in each room. The First Aid kit is kept in the front office 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 an offices. The last fire drill was conducted on 04/19/2023 and the disaster/earthquake drill was conducted on 04/05/2023.

LPA reviewed medication for 5 clients and observed that medications are documented properly and given as prescribed. LPA reviewed 5 client and 5 staff records. LPA also reviewed the administrator's records to determine if administrator meets the required qualifications per Tittle 22, Chapter 2, Section Code 81064. LPA interviewed 4 clients and 3 staff. Facility manages funds for 4 clients only and LPA reviewed the funds for these 4 clients with a staff present. Facility has the required surety bond. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAFE HAVEN
FACILITY NUMBER: 198603048
VISIT DATE: 06/13/2023
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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: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC809 (FAS) - (06/04)
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