The complaint alleges that Staff are not properly trained. LPA reviewed training records of 8 of 20 staff which indicated that training was complete on 8 of 8 inspected. According to interview with Administrator, staff are trained as per Title 22 regulations. In addition, staff receive trainings at regular staff meetings and training per Yolo County Care Continuum (YCCC) protocols and guidelines. LPA interviewed staff on site during a visit on 9/30/2025 and 3 of 3 staff members stated that they received adequate training and felt properly trained. Interview with Administrator on 09/30/2025 stated that staff are provided with resources including the facility’s psychiatrist, behaviorists and administrator for any questions regarding clients. Based on the records reviewed, interviews with staff and administration at the facility the allegation that Staff are not properly trained is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Staff are not properly trained is unsubstantiated

(Continued on 9099-C)

The complaint alleges that Facility is in disrepair. The complainant stated that “Safe Harbor has also presented with safety concerns with the environment such as cracks in the walls that may suggest issues with infrastructure that have not been well maintained. Safe Harbor has not had the building inspected for such issues despite staff and other clients reporting their observations to management. Clients have consistently had issues with the quality of living, such as broken and dirty furniture and broken bathrooms/plumbing that does not get addressed in a timely manner.” LPA Nakagawa inspected the facility on multiple occasions, 1/8/2025, 6/17/2025, 8/19/2025, 9/30/2025, 10/07/2025 and found no signs of negligence on the part of the Licensee or the Administrator regarding the safety of the building. LPA found no signs of cracks in the walls and bathroom fixtures were all intact and functioning with the facility providing hot showers and flushing toilets throughout the building. The kitchen flooring was recently replaced prior to visit on 6/17/2025 . LPA found the kitchen appliances working on all four visits and the staff chef was pleased with their functionality. In addition, new couches were in place in the living room as of the visit on 8/19/2025. The old couches, although well-worn, were not ripped or broken, and provide extra seating outside for the summer. According to the Administrator, the old couches will be discarded prior to the wet weather but were outside because of client requests. All clients’ rooms were inspected and found to be clean and in good repair and had the required furniture and linens. Facility lights and air conditioning were functioning. Through inspections of the facility on 1/8/2025, 6/17/2025, 8/19/2025 and 9/30/2025and 10/07/2025 and interviews of staff and clients, LPA could find no evidence of the facility being in disrepair. Although the allegation may have occurred there is no preponderance of evidence therefore the allegation that the facility is in disrepair is UNSUBSTANTIATED.

The complaint alleges that staff are providing medication without a prescription. The complainant stated that staff at this facility have also been told to allow clients to skip medication passes. LPA reviewed the Medication Administration Record (MAR) and found no irregularities. Administrator stated upon admission clients receive paperwork authorizing the facility to administer their medications, which are ordered by a licensed physician/psychiatrist. The orders may include over the counter medications such as Tylenol, antacids, cold and flu medications, or other medicines as needed deemed necessary by the ordering physicians. The complainant also states that clients are told to skip medication passes. Administrator stated all staff at the facility are required to assist clients with medications as ordered by the physician, however it is understood it is the personal right of the client to refuse medication. LPA was unable to reach the complainant to verify any specific case and LPA’s inspection of MAR found no evidence of medications being provided without a prescription. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation that Staff are providing medications without a prescription is UNSUBSTANTIATED..

The complaint alleges that Staff do not follow Admissions Procedures. The complainant stated that Safe Harbor has allowed clients to remain at the facility for the sake of how much the county is paying for beds, rather than assessing whether a client is a good fit for the program and would thrive in a crisis residential environment. Clients have been accepted and allowed to stay at least 1 night despite refusing to fill out consent forms, having a lack of proper documentation stating their medications have been signed off by a licensed physician, and clients that require proper ADA accommodation but were not properly accommodated. LPA reviewed Title 22 regulation which has admission procedures particular to Social Rehabs and Crisis Clinics, which states “… information may not be readily available for clients accepted in a short-term residential crisis program. If this information is not available at the time of admission, this fact must be documented in the client's file, and the information must be obtained within three days of admission to the program”. LPA reviewed 8 client files and found that 8 of 8 files were complete. Interviews with staff and Administrator did state that occasionally clients do not have paperwork completed prior to admission but they do not accept clients without a medical assessment and medications. Based on review of client records and staff interviews the allegation that Staff do not follow the facilities admissions procedures is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation Staff do not follow the facilities admissions procedures is UNSUBSTANTIATED.