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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800127
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:49:53 AM

Document Has Been Signed on 09/09/2024 11:49 AM - 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/
DIRECTOR:		WILSON, PAULAFACILITY TYPE:
735
ADDRESS:15821 MCVAY LANETELEPHONE:
(760) 221-1637
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 4CENSUS: 3DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Araceli TorresTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Araceli Torres, Direct Support Provider II (DSP) and discussed the purpose of the visit. The facility is an Adult Residential facility with a license capacity of (4) and a current census of (3). During LPA's visit, there was one client at the facility and the other (2) clients were attending program. The facility is a certified Inland Regional Center (IRC) vendor. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: The facility maintains an infection control plan and a current disaster drill record on file. The facility has 24 hour/7 days a week care staff. Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility is equipped with operating smoke/carbon monoxide alarms and telephone service. The facility has sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and sufficient lighting. Client bathroom toilets, hand washing basins and showers were operating in safe conditions. The hot water in client bathrooms tested at 107 degrees F. Sharps, disinfectants and cleaning supplies were kept locked, inaccessible to clients in care.

Food Service: The facility’s kitchen area was maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezers and refrigerators were in operating in a healthful manner.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SAFE HAVEN HOME I
FACILITY NUMBER: 361800127
VISIT DATE: 09/09/2024
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Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked room.

Personnel/Client Records: Staff records reviewed had health screenings, criminal record clearances, and first aid/CPR training certifications. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs. Review of client records reveals client #1(C1) and client #2 (C2) do not have current needs and service plans on file for review. C2's personal & incidental (P&I) record log is not up-to-date, last log entry was 6/12/24; however there are purchase receipts from june 2024 through September 2024 that were not logged.

Based on LPA observations and record review, deficiencies are being cited per Title 22 of the California Code of Regulations.

An exit interview was conducted were the licensing reports were discussed. Copies of the reports with appeal rights was provided to the DSP at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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Document Has Been Signed on 09/09/2024 11:49 AM - It Cannot Be Edited


Created By: Magda Malcore On 09/09/2024 at 11:04 AM
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: 09/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
Safeguards for Cash Resources, Personal Property and Valuables
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining current needs and service plans for C1 & C2 on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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The Licensee/Administrator has agreed to provide accurate logs to Licensing for review by POC due date.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above by not maintaining current needs and service plans for C1 & C2 on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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The Licensee shall provided current needs and service plans to Licensing for review 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:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024


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