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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:05:00 PM

Document Has Been Signed on 03/11/2022 01:05 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:
03/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:La Shell Mitchell, Program Manager and
Katrina Brass, QIC		TIME COMPLETED:
01:10 PM
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Licensing Program Analyst Jill Nakagawa arrived unannounced on 03/11/22 and met with La Shell Mitchell, Program Manager and Katrina Brass, QIC, to discuss the operational plan for the admission of clients who will be receiving methadone treatments on a daily basis.

LPA Nakagawa went over the daily operational plan, including transportation to and from the clinic for treatment, supports from the on-site clinician, pharmacy back-ups, transportation back-ups, staffing concerns and training, the support plan and the agreement with the client. There will be close communication with the Case Manager as well as the three Psych. physicians. There is also an On-Call in place. Transportation has been secured for 6 days a week. The clinic is not open on Sundays so the client will bring a lock-box with them to the Saturday appointment and the clinician will lock the Sunday dosage in the lock-box where it will be returned for the Medication Technician to administer on Sunday morning. There is a separate MAR specifically for the Methadone administration. Client will be aware of the protocols and will sign Client Agreement. Also, ideally, client will be receiving treatment from the same clinic they have already been going to before.

LPA requested a copy of the MAR, Client Agreement, Operational Plan and Client's Medical Clearance Form and Medical Background/Intake Information; and copy of proof of staff training.

No deficiencies were found during today's inspection.
No citations issued at this time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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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