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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426348
Report Date: 07/03/2024
Date Signed: 07/03/2024 01:20:44 PM

Document Has Been Signed on 07/03/2024 01:20 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/
DIRECTOR:		BAYSINGER, ROYFACILITY TYPE:
735
ADDRESS:12779 2ND AVENUETELEPHONE:
(951) 544-2135
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 4DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:18 AM
MET WITH:Danielle Baysinger-StaffTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Danielle Baysinger and introduced self and stated the purpose of the visit. LPA was informed that there is currently 1 client home, 2 in program and 1 in an outing.

The facility has 4 client bedrooms, 3 bathrooms in which one is private for staff, 2 staff bedrooms, 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 77 degrees Fahrenheit temperature. LPA inspected clients bedrooms; they are equipped with required furniture per regulations. LPA observed an adequate supply of linens stored in the hallway closet. LPA inspected clients bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the water temperature which tested at 106.5 degrees Fahrenheit. The facility is equipped with operating smoke detectors, carbon monoxide alarms and 2 fire extinguishers. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked. There was a designated locked storage space for clients/staff files, first aid kit and medication. There are no pools, bodies of water, firearms or ammunition.

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. LPA observed a client's medication inside the refrigerator making it accessible to one client present in the facility. Deficiency issued. Dishes, cups, and utensils were stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348
VISIT DATE: 07/03/2024
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Record Review: LPA reviewed administrator and staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA observed a missing physician's assessment for one client. Deficiency issued. P & I funds were counted at random and matched with the ledger. LPA reviewed the emergency disaster plan and emergency disaster drills. LPA observed that the disaster drills were conducted at the same time with no variation in shift. Technical violation issued.

Deficiencies and one technical violation were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to Danielle Baysinger.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2024 01:20 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/03/2024 at 12:54 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in making a client's medication inside the refrigerator accessible to one client present in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Staff removed the medication from the refrigerator and stored it inside the inaccessible refrigerator inside the garage. Licensee stated that he will submit a statement of understanding on deficiency issued and send proof to LPA via email by POC due date.
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as 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 licensee did not comply with the section cited above in including a medical assessment inside the client's file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Licensee stated that he will send a copy of the client's medical assessement and include a copy in the cllent's file.
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: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


LIC809 (FAS) - (06/04)
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