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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800127
Report Date: 09/11/2023
Date Signed: 09/11/2023 01:32:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2023 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230801140621
FACILITY NAME:SAFE HAVEN HOME IFACILITY NUMBER:
361800127
ADMINISTRATOR:WILSON, PAULAFACILITY TYPE:
735
ADDRESS:15821 MCVAY LANETELEPHONE:
(760) 221-1637
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY:4CENSUS: 3DATE:
09/11/2023
UNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Tonisha Stacy, caregiverTIME COMPLETED:
01:38 PM
ALLEGATION(S):
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Staff did not manage resident's medications correctly resulting in resident getting hospitalized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegation. LPA met with caregiver Tonisha Stacy and explained the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties.

The allegation alleged medication errors resulting in resident #1 (R1) hospitalization. LPA Nickolas’ interview with the reporting party (RP) revealed that the RP denied making this allegation. LPA Nickolas' interview with staff #1 (S1) revealed that all residents in care medications are in bubble packs. S1 stated that the bubble packs are labeled by date and time of day to administer medication. S1 stated that medication is administered to residents according to the date and time labeled on the medication bubble pack. LPA Nickolas was unable to interview R1 during the initial compliant investigation visit because they were in the hospital. LPA Nickolas’ medication audit of all residents in care revealed no discrepancies. LPA Nickolas’ medication audit also revealed that the Medication Administrator Records (MARs) were accurately documented for all residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 56-AS-20230801140621
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: SAFE HAVEN HOME I
FACILITY NUMBER: 361800127
VISIT DATE: 09/11/2023
NARRATIVE
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The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and copy of this report was provided.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4