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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 11/05/2021
Date Signed: 04/27/2022 01:28:03 PM

Document Has Been Signed on 04/27/2022 01:28 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:
(530) 661-3213
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 7DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Juan Andres, Program Director TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa met with Juan Andres, Program Director for a Case Management- Incident Inspection, on 11/05/2021 at approximately 11:42 AM. 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 2 clients' medication errors: Client C1 had three (3) 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 10/20/2021 (2 separate incidents) and 10/24/2021 (one (1) incident; and Client C2 who was administered the wrong dosage of a medication on 10/19/2021.

During today's visit, LPA met with Juan Andres, Program Director and went through a review of medication records, protocols, policies and incident reports. The facility was previously cited (1/12/2021) and (10/21/2021) for failure to issue medications as prescribed.

Deficiencies cited from the California Code of Regulations (CCRs), Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. An immediate Civil Penalty in the amount of $250.00 is assessed for Medications Not Being Administered as Prescribed .
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 04/27/2022 01:28 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 11/05/2021 at 11:44 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
, 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
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 11/10/2021. 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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 Protocols and Procedures of Medication Administration will be updated and submitted to CCL by 11/16/2021.***Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months.

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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: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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