<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 03/07/2023
Date Signed: 03/14/2023 04:26:47 PM

Document Has Been Signed on 03/14/2023 04:26 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: 6DATE:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Sharonda Watson, Program Director
and Rachel Yang, Clinical Director		TIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nakagawa conducted an unannounced case management inspection and met with Administrator Watson The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) on 1/9/2023.

On 1/5/2023 Client (C1) received the wrong dosage of a prescribed medication within a 24 hour period. Per the incident report, staff failed to review the dosage and time of dosage and client was over-medicated.

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 (Medication Administration Record) MAR for all staff to review prior to medication administration. Additional staff training has been on-going.


***Civil penalties in the amount of $250.00 are being assessed due to repeat violations in the past 12 months for regulation 81075(b) previously cited on 6/17/2022.


Deficiencies cited from the California Code of Regulations, 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 civil penalties. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 03/14/2023 04:26 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 03/07/2023 at 02:41 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: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2023
Section Cited
CCR
81075(b)

1
2
3
4
5
6
7
81075(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.**This requirement is not met as evidenced by:


1
2
3
4
5
6
7
POC: Facility has provided proof of additional training provided to staff since the incident in addition to additional safety measure being put in place prior to medication administration(POC cleared at visit)
8
9
10
11
12
13
14
Based on record review and interview with Program and Clinical Directors, the facility failed to ensure C1's medication was given as prescribed by a physician which poses an immediate health and safety risk to Client in care.

8
9
10
11
12
13
14

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.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2