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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426348
Report Date: 07/17/2024
Date Signed: 07/17/2024 10:26:45 AM

Document Has Been Signed on 07/17/2024 10:26 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/
DIRECTOR:		BAYSINGER, ROYFACILITY TYPE:
735
ADDRESS:12779 2ND AVENUETELEPHONE:
(951) 544-2135
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 4DATE:
07/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:52 AM
MET WITH:Roy Baysinger-LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:32 AM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240708151212. LPA met with Licensee, Roy Baysinger. During today's visit, LPA conducted observations. LPA found the following issues:
  • Pantry was not clean and sanitary and rodent droppings were found.
  • Food in pantry was not safe to consume due to past expiration date.
These pose a potential health and safety risk to clients in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report, LIC809, LIC809D, and appeal rights were discussed with and provided to Licensee, Roy Baysinger.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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Document Has Been Signed on 07/17/2024 10:26 AM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/17/2024 at 09:50 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: SAFEGUARD ADULT HOME I
FACILITY NUMBER: 366426348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2024
Section Cited
CCR
80076(a)(17)

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80076(a)(17) Food Services
(a) In facilities providing meals to clients, the following shall apply:(17)All kitchen, food preparation, and storage areas shall be kept clean, free of litter and rubbish, and measures shall be... vermin. This requirement is not met as evidenced by:
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Licensee stated that he just created a kitchen check list for staff to maintain it clean and will submit a copy to LPA via email by POC due date.
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Based on observation, the licensee did not comply with the section cited above in making sure that the kitchen was kept clean and sanitary which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/19/2024
Section Cited
CCR80076(a)(1)

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80076(a)(1) Food Services
(a) In facilities providing meals to clients, the following shall apply:(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each... healthful manner. This requirement is not met as evidenced by:
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Licensee stated the he just created a pantry check list for staff to maintain the food inside the pantry and refrigerator up to date and will submit a copy to LPA via email by POC due date.
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Based on observation, the licensee did not comply with the section cited above in making sure that the food in the pantry was up to date which poses a potential health, safety or personal rights risk to persons in care.
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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: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
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