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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200055
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:14:22 PM


Document Has Been Signed on 08/29/2024 04:14 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:WILLIAMS-WHITTLE RESIDENTIAL HOMEFACILITY NUMBER:
107200055
ADMINISTRATOR:WILLIAMS-WHITTLE, CHERYLFACILITY TYPE:
735
ADDRESS:821 W. VALENCIATELEPHONE:
(559) 441-8266
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY:6CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Facility Staff, Dauglas Idoni and Raeisha Sykes.
TIME COMPLETED:
01:04 PM
NARRATIVE
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On 08/29/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff granted LPA entry to the facility and attempted to contact Administrator via telephone but were unsuccessful. LPA met with facility staff, Dauglas Idoni and Raeisha Sykes. Licensee, Lucile Williams was present during today's inspection.

LPA conducted a tour of the facility. During the inspection the facility appeared clean and odor free and at a comfortable temperature. LPA observed a hole in the ceiling in the dining room, the door chime and smoke detector in the hallway need to be reattached to the facility. LPA observed the deadbolt lock to be missing from the garage door leaving a large hole exposed. Common areas were furnished. LPA observed a chair in need of cleaning and an ottoman needing to be repaired or replaced. Resident bedrooms appeared clean and had required furnishings and adequate lighting. Multiple outlet covers were observed to be missing. LPA observed a hole in the wall of room 1. Residents bathrooms appeared clean, water temperature measured at 107.8 degrees F. LPA observed a razor to be accessible to clients in care in an open cabinet in the bathroom. Facility kitchen appeared to be clean and safe for food preparation. LPA observed an adequate food supply.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. Fire extinguisher is current with a service date of 02/27/2024. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 05/27/2024. Cleaning supplies observed to be locked in a cabinet in the garage. Client and personnel records are not maintained at the facility

CONTINUED TO 809D

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL HOME
FACILITY NUMBER: 107200055
VISIT DATE: 08/29/2024
NARRATIVE
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LPA reviewed medications and medications records. Upon review, LPA found that R1 did not have a medication refill for Bisacodyl. Facility staff stated the medication was reordered "yesterday". The medication pack was empty and review of records revealed that the medication was not signed off as administered on 08/28/2024.

House Manager, Christopher Maxey, arrived with client and personnel records.

Upon review of records, LPA found that 1 out of 4 clients do not have a current IPP on file. Personnel records were found to be complete and current.

Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A civil penalty in the amount of $250 is being assessed for a repeat violation.

Exit interview conducted and a plan of correction was reviewed and developed with Licensee and House Manager. A copy of this report and appeal rights were provided via email and a hard copy will be mailed to the facility. Reports signed on-site by house manager.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/29/2024 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL HOME
FACILITY NUMBER: 107200055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when a razor was observed to be accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.
Type A
Section Cited
CCR
80075(b)
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 when the facility did not have refill medication for R1 and the medication records did not indicate the medication was administered, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 08/29/2024 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL HOME
FACILITY NUMBER: 107200055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when multiple items throughout the facility were in need of repair, replacement, and/or cleaning which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2024
Plan of Correction
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Licensee agrees to make the necessary repairs by the POC due date. LPA will return at a later date to verify if repairs have been made.
Type B
Section Cited
CCR
80068.3(a)
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

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 when 1 out of 4 clients did not have a current IPP on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee agrees to obtain a copy of the IPP for R2 and submit the IPP to the Fresno CCL office by the POC due date.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 08/29/2024 04:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WILLIAMS-WHITTLE RESIDENTIAL HOME
FACILITY NUMBER: 107200055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
(e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when personnel records are not maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee agrees to maintain a copy of the personnel records to the Fresno CCL office and submit a written statement detailing the personnel records are kept in the facility by the POC due date.
Type B
Section Cited
CCR
80070
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above when client records were not maintained in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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3
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Licensee agrees to maintain a copy of the client records to the Fresno CCL office and submit a written statement detailing the client records are kept in the facility by the POC due date.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5