<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426348
Report Date: 06/14/2023
Date Signed: 06/14/2023 05:20:06 PM

Document Has Been Signed on 06/14/2023 05:20 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:SAFEGUARD ADULT HOME IFACILITY NUMBER:
366426348
ADMINISTRATOR:BAYSINGER, ROYFACILITY TYPE:
735
ADDRESS:12779 2ND AVENUETELEPHONE:
(951) 544-2135
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 4DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Roy Baysinger-AdministratorTIME COMPLETED:
05:26 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/14/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Roy Baysinger, and introduced self and stated the purpose of the visit. LPA was informed that there are currently 4 residents in care.

The facility has 4 resident bedrooms, 2 bathrooms, 1 staff bedroom along with 1 private bathroom, front room, kitchen, living room, attached garage, and backyard.

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility is maintained at a 79 degrees Fahrenheit temperature. LPA inspected residents bedrooms; they are equipped with required furniture per regulations. LPA observed a hole on the staff's bedroom door. Deficiency issued. An adequate supply of linens stored in the hallway closet. LPA inspected residents bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature in the kitchen faucet which tested at 115.8 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. The facility has 2 fire extinguishers. Posters such as; the personal rights and disaster plans were posted in a common area. LPA observed that the Emergency Disaster Plan has not been reviewed since 12/31/2023. Deficiency issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for residents/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition. LPA observed the windows in the kitchen and living room with dust settled and dead flies on the bottom and floors. Deficiency issued.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. There are 2 sheds that are used for storage.

Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Facility has a variety of food available. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/14/2023 05:20 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/14/2023 at 04:08 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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in not maintaining the facility sanitary and in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
1
2
3
4
Licensee stated that he will cover the hole on the staff's door, clean the windows and submit proof to LPA by POC due date with picture of repair and cleaned windows via text or email.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in keeping the facility free of flies which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
1
2
3
4
Licensee stated that he will clean the flies on the floor and maintain the facility clean to avoid the flies going inside. Licensee stated that he will review regulation 80087(a)(1) with staff and submit proof of acknowledgment by POC due date via text or email.
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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/14/2023 05:20 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 06/14/2023 at 04:08 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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in reviewing the Emergency Disaster Plan annually which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2023
Plan of Correction
1
2
3
4
Licensee stated that he will update the Emergency Disaster Plan and submit proof by providing a copy to LPA via text or email on POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348
VISIT DATE: 06/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Record Review: LPA reviewed 2 residents files along with 2 staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

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 Administrator, Roy Baysinger.

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

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4