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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 10/21/2021
Date Signed: 10/21/2021 05:04:26 PM

Document Has Been Signed on 10/21/2021 05:04 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CAREFACILITY NUMBER:
577003619
ADMINISTRATOR:KEVIN MACNEILLFACILITY TYPE:
772
ADDRESS:584 KENTUCKY AVENUETELEPHONE:
5306613213
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 4DATE:
10/21/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Juan Andres, Program Director
Elizabeth Hall, Administrator, Amber Salazar, E.D.
Katrina Brass, QIC		TIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa met with Juan Andres, Program Director; Elizabeth Hall, Administrator; Amber Salazar, Executive Director; and Katrina Brass, QIC for a Case Management- Incident Inspection, on 10/21/2021 at approximately 2:00 PM. The inspection is being conducted to review clients' incident reports to determine the safety of medication administration at the facility.

LPA conducted an incident report review of two clients medication errors; per conferencing with administration and review of medication records, the licensee did not ensure that Client C1 was administered the correct medication on 9/16/2021, C1's pharmacist was notified. In addition, another incident report on 09/23/2021, indicated that staff did not administer a medication to C2, due to staff misreading medication record.

During today's visit, LPA met with facility staff and went through a review of medication records, protocols, policies and incident reports. While reviewing, LPA learned of 2 new medication errors which the facility is still reviewing and will be reported to Community Care Licensing within the required time frame. The facility was previously cited (1/12/21) for failure to issue medications as prescribed and for failure to report incidents.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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 10/21/2021 05:04 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 10/21/2021 at 03:26 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CARE
FACILITY NUMBER: 577003619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2021
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services. Medications shall be given according to physician's directions.

This requirement is not met as evidenced by:
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Licensee/administrator will enroll all staff in a medication course from an outside approved vendor by 11/01/2021. Staff involved in medication errors must be trained by POC date-submit a summary of the training and provide an attendance record with participant signatures; send to CCL no later than 11/16/2011. Protocols and Procedures of Medication Administration will be updated and submitted to CCL by 11/01/2021.
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Based on record review and interview with staff and administration the facility failed to administer medication as ordered. This poses an immediate health and safety risk to clients 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:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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