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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426348
Report Date: 01/10/2024
Date Signed: 01/10/2024 11:27:02 AM

Document Has Been Signed on 01/10/2024 11:27 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: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:
01/10/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Roy Baysinger- AdministratorTIME COMPLETED:
11:30 AM
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On 01/10/24, Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced POC visit in order to inspect for corrected deficiencies cited on 12/18/23. LPA introduced self and was granted entrance by Administrator, Roy Baysinger.

During today's visit, LPA made physical observations of the facility and reviewed records.
  • Deficiency 80075(k)(1) has been cleared. Licensee complied with the terms of the POC as LPA reviewed completed required training certificate and sign in sheet.
  • Deficiency 80088(b) has been cleared. Licensee submitted installed window screen pictures as proof to LPA's email. LPA observed the missing window screens replaced.
  • Deficiency 80072(a)(7) has been cleared. Licensee complied with the terms of the POC. LPA observed the lock removed from the right side gate and the exits cleared and not obstructed.
  • Deficiency 85064(b) has been cleared. Licensee complied with the terms of the POC. LPA reviewed the statement of understanding and the administrator's certificate.
  • Deficiency 80026(h)(1) has been cleared. Licensee complied with the terms of the POC. LPA reviewed the statement of understanding submitted.
  • Deficiency 80075(b) has been cleared. Licensee complied with the terms of the POC. LPA reviewed the required training and sign in sheet.
  • Deficiency 1565(d) has been cleared. Licensee complied with the terms of the POC. LPA reviewed the submitted Emergency Disaster Plan.
  • Deficiency 80070(c)(1) has been cleared. Licensee complied with the terms of the POC. LPA observed the records locked and inaccessible to clients. LPA also reviewed the statement of understanding submitted.
  • Deficiency 80061(b)(1)(E) has been cleared. Licensee complied with the terms of the POC. LPA reviewed the required training and sign in sheet.

Letters of Cleared POC were issued during today's visit. This report was reviewed with and a copy was provided to Roy Baysinger.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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