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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002629
Report Date: 09/07/2023
Date Signed: 09/07/2023 11:38:13 AM

Document Has Been Signed on 09/07/2023 11:38 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:STEPPING STONES CCFFACILITY NUMBER:
045002629
ADMINISTRATOR:KUSSEROW-FRAZIER, ANNETTEFACILITY TYPE:
735
ADDRESS:215 VALLEY VIEW DRTELEPHONE:
(530) 534-4464
CITY:OROVILLESTATE: CAZIP CODE:
95966
CAPACITY: 6CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Annette Frazier - licenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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09/07/2023 09:15 AM Licensing Program Analysts (LPAs) Rebecca Knight and Jaynae Boyles arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA s met with licensee/ administrator Annette Frazier and explained the purpose of the visit.

LPAs and the administrator toured the facility together to ensure the health and safety of clients in care. Areas toured include but are not limited to four (4) client rooms, common areas, two (2) bathrooms, kitchen, storage areas and back yard. Staff and resident files were reviewed.

Bedding, linens, and towels for clients were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the clients. Medication is locked in a cabinet.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area in good repair but cluttered. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and were inspected in September 2022 and are due for replacement. Smoke detectors are all operational. No pools/bodies of water are on premises. No firearms are on premises. Last disaster drill was conducted in August 2023 which was a fire drill, the facility has been conducting fire drills monthly.

The following deficiencies are being cited on the attached LIC809-D in accordance with California Code of Regulations, (Title 22). Administrator certificate is expired. One staff who requires background clearance transfer is not associated to the facility.

Appeal rights were provided, and an exit interview conducted, a copy of the report was provided to licensee / administrator Annette Frazier.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 09/07/2023 11:38 AM - It Cannot Be Edited


Created By: Rebecca Knight On 09/07/2023 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 4 personenel files which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2023
Plan of Correction
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Licensee agrees to complete criminal records clearance transfer request for 1 staff. Licensee will submit completed association and criminal background clearance to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/07/2023 11:38 AM - It Cannot Be Edited


Created By: Rebecca Knight On 09/07/2023 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: STEPPING STONES CCF
FACILITY NUMBER: 045002629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records revikew the licensee did not comply with the section cited above in 1 of 1 administrator files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2023
Plan of Correction
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Administrator agrees to submit all training records and paperwork to renew expired administrator certificate. Administrator will submit new certificate to LPA by 10/05/2023 as proof of correction.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023


LIC809 (FAS) - (06/04)
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