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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 06/17/2022
Date Signed: 06/17/2022 01:53:16 PM

Document Has Been Signed on 06/17/2022 01:53 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAFE HARBOR CRISIS HOUSE-YOLO COMMUNITY CAREFACILITY NUMBER:
577003619
ADMINISTRATOR:HALL, ELIZABETHFACILITY TYPE:
772
ADDRESS:584 KENTUCKY AVENUETELEPHONE:
(530) 661-3213
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 3DATE:
06/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:La Shell Mitchell, Program Director
Katrina Brass, QIC		TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to review the circumstances surrounding an incident report submitted to Community Care Licensing . At the time of LPA's arrival, there were 3 clients, with a fourth expected later that day. There were 2 staff and 2 administrators on site as well.

The self-reported incident occurred on May 14, 2022 and involved a client receiving the wrong dosage of prescribed medication. Per the incident report, staff failed to review the dosage and client was under-medicated. The underdosage of medication was reported to Program Director and medical team.

LPA reviewed the facility's "Medication Protocol" with Program Director. Additional safeguards and precautions have been put in place. Staff meet at change of shift to review any medication changes with on-coming staff; med lists are included at the front of the MAR for all staff to review prior to medication administration. In addition, a nurse is being added to the staff several days a week, and a doctor from Yolo County will now be overseeing clients and their care, including their medications and prescriptions.

LPA is citing the facility for failure to assist a client with with self-administration of prescription medications.

Deficiencies are cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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 06/17/2022 01:53 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 06/17/2022 at 12:21 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
, 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: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited
CCR
81075(b)

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81075 Health-Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

***This requirement has not been met as evidenced by:
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Facility has conducted additional training for involved staff; additional staff have been hired, including a nurse. Also, County physician is now overseeing each clients' care, providing continuity and oversight. Program Director has put additional safety measures in place.
Deficiency is cleared.
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...report that client took an incorrect dosage of their medication.

This is an immediate risk to the health and safety of 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: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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