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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800127
Report Date: 09/06/2023
Date Signed: 09/06/2023 03:41:15 PM

Document Has Been Signed on 09/06/2023 03:41 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jennifer Moorer- House ManagerTIME COMPLETED:
03:50 PM
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On 09/06/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with house manager, Jennifer Moorer, introduced self and stated purpose of the visit.

The facility has 4 client bedrooms, 3 bathrooms, office, kitchen, dining room, living room, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees farenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 109.6 degrees farenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguishers, and first aid kits. Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. LPA observed the emergency disaster drill outdated, not reviewed and missing a signature. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets inaccessible to clients. Medications and clients/staff files were observed inside the office made inaccessible to clients. The facility had emergency kits, emergency food and water in the garage. There are no pools, bodies of water, firearms or ammunition. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 03:41 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 09/06/2023 at 03:07 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SAFE HAVEN HOME I
FACILITY NUMBER: 361800127

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in having a complete and signed physician's report for one of the client's which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
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Administrator stated that she will have the physician sign the physician's report for the client that has an incomplete physician's report and submit proof to LPA via email by POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the administrator did not comply with the section cited above in updating and reviewing the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2023
Plan of Correction
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Administrator stated that she will update and review the emergency disaster plan annually and submit proof to LPA via email by POC due 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFE HAVEN HOME I
FACILITY NUMBER: 361800127
VISIT DATE: 09/06/2023
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Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA observed the physician's signature missing on the Physician's report for one of the client's. Deficiency issued. LPA also reviewed administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. The facility last conducted a fire drill in July 29, 2023.

Two deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and appeal rights were discussed and copies were provided to the house manager, Jennifer Moorer.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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