577003619-2-10-2023-21-AS-KMOA-CPBV7Y-20230223151152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577003619
Report Date: 02/10/2023
Date Signed: 02/10/2023 01:47:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Jill Nakagawa

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230113142520

FACILITY NAME:	SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CARE		FACILITY NUMBER:	577003619
ADMINISTRATOR:	HALL, ELIZABETH		FACILITY TYPE:	772
ADDRESS:	584 KENTUCKY AVENUE		TELEPHONE:	(530) 661-3213
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	14	CENSUS: 2	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Sharonda Watson, Program Director		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff are not qualified to administer medication to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced for the purpose of delivering complaint findings regarding the above allegation. LPA met with Sharonda Watson, Program Director, and was granted access into the facility.

During the course of the investigation, LPA Nakagawa made several visits to the facility (01/17/2023, 01/26/2023, 02/10/2023) and made observations, conducted interviews and reviewed records.

The complaint alleges that staff are not qualified to administer medication to residents. LPA attempted to review staff training records and found that past administrator had failed to keep any training records so no documentation verifying staff training on administering medications was found.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230113142520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CARE	FACILITY NUMBER: 577003619
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/10/2023 Section Cited CCR 81065(r)(2)	1 2 3 4 5 6 7	81065Personnel Requirements(r)All direct care staff shall receive a minimum of 20-clock-hours of continuing education.(2)The licensee shall document...completed each year by direct care staff. This requirement was not met as evidenced by: Based on records review and staff interview,	1 2 3 4 5 6 7	Plan if Correction: Facility to send in written statement they understand regulation and how they will meet the requirement. Facility to provide and send proof of staff training.
	8 9 10 11 12 13 14	staff training could not be verified. This poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Written statement of plan due by 2/13/2023 and staff training due to begin by 2/15/2023. Written documentation of staff training schedule to be submitted to LPA by 2/13/23 and completion of staff training (20 hours) to be submitted to LPA by 3/15/23.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230113142520

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CARE	FACILITY NUMBER: 577003619
	VISIT DATE: 02/10/2023

NARRATIVE

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Continued from 9099

Therefore, based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiency was observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 2 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights and this report were reviewed with Program Manager.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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