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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 08/13/2021
Date Signed: 08/30/2021 07:49:13 AM

Document Has Been Signed on 08/30/2021 07:49 AM - 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: DATE:
08/13/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amber Salazar, Executive DirectorTIME COMPLETED:
12:45 PM
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An informal meeting was conducted today in the Rohnert Park Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were, Licensing Program Manager, Hope DeBenedetti, Licensing Program Analyst, Katrina Walters and Licensing Program Analyst, Jill Nakagawa, Associate Director, Juan Andres, Program Director, Elizabeth Hall, Executive Director, Amber Salazar and Quality Assurance Coordinator, Katrina Brass.

The purpose of the informal office meeting was to discuss ongoing concerns that have been identified with the facility’s management of client medication and a Plan of Correction to rectify the errors.

The following was discussed during the office meeting:
  • Reporting Requirements- Ensuring all Incident reports submitted to Licensing according to Title 22 regulation.
  • Facility’s Medication Policy-Ensuring staff are receiving training, understand and are following the facility’s policy
  • Medication administration-Ensuring residents are receiving the proper doses of the medication prescribed to them at the proper times and facility’s procedure of what to do when the facility does not have a residents medication
  • Medication Destruction procedures-Ensuring facility staff are following facility’s own medication destruction plan
  • Facility’s plan for future compliance

Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 CARE
FACILITY NUMBER: 577003619
VISIT DATE: 08/13/2021
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Continued from 809

Licensee has agreed to make changes and will submit the following to Community Care Licensing, attention Licensing Program Analyst, Jill Nakagawa and Katrina Walters:
  • Licensee to submit an updated policy and procedure in regards to reporting by Friday, 8/20/2021.
  • Licensee to submit proof of medication training and proof that buddy pass system has been implemented by Friday, 9/10/21.
  • Facility will revise medication policy in regards to medication practices and send updated policy by 8/25/21.
  • Licensee to submit plan for contract with an outside vendor, who will provide training to Licensee and Staff. Plan should include services, training topics to be covered, date and hours of training and list of attendees. Plan to be submitted by 8/20/2021.


Failure to submit the items above and take necessary corrective action may result in the Department seeking further action.

No deficiencies cited for this facility.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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