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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:06:21 PM

Document Has Been Signed on 08/16/2022 12:06 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:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Katrina Brass, QICTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection focusing on Covid-19 Infection Prevention and Protocols. There are currently 3 residents at the facility.

LPA was met at the door by staff and screened for Covid-19 symptoms, temperature taken and information was logged. QIC Katrina Brass met LPA and toured the facility. Facility was clean and orderly, and a comfortable temperature. Residents' rooms were clean and had the required furnishings. Bathrooms were supplied with paper towels and hand soap. There was hand sanitizer available upon request but not out in the open due to resident behaviors. The kitchen had ample supply of food and snacks available at all times, including bottled water for residents' hydration.

Two (2) residents were enjoying the comforts of the living room, watching a large screen TV at the time of the inspection. The living room provides ample room for social distancing. There is also a small area set up for arts and crafts. There is a shady area to sit outside. The facility also provides a private visitation area.

Staff are receiving monthly training through Health Stream covering Universal Precautions as well as other required subjects. There is a training on Narcan being scheduled with other sister facilities in the near future. The facility is currently looking for a new Program Director and Program Assistant.

LPA requested updated copies of the LIC 500, Control of Property, Admission Policies and Procedures/Admissions Agreement, Liability Insurance, Theft and Loss Policy and Transportation Procedures.

There were no deficiencies found at the time of this inspection.

No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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