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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577003619
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:19:47 PM

Document Has Been Signed on 09/07/2023 05:19 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: 5DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Katrina Brass, QID
Sharonda Watson, Future Administrator		TIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. There are currently 5 residents at the facility.

LPA was met at the door by staff and logged in. QID Katrina Brass and Sharonda Watson, Future Administrator 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. The kitchen had an ample supply of perishable and non-perishable food and snacks available at all times. There was a great variety in the choices of foods at this time.

Two (2) residents were enjoying the comforts of the living room, watching a large screen TV at the time of the inspection. Two (2) other residents were outside enjoying the patio and playing basketball. There is also an area set up for arts and crafts, music and lots of reading materials. The facility also provides a private visitation area. Staff are receiving monthly training through Health Stream.

LPA requested updated copies of the LIC 500, Control of Property, Liability Insurance.
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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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