<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200659
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:19:21 PM


Document Has Been Signed on 05/03/2024 12:19 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #2FACILITY NUMBER:
107200659
ADMINISTRATOR:WILLIAMS-WHITTLE, CHERYLFACILITY TYPE:
735
ADDRESS:4112 W. PROVIDENCE AVENUETELEPHONE:
(559) 276-7407
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 3DATE:
05/03/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Yashica TurnerTIME COMPLETED:
12:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Staff (S1) Yashica Turner. LPA contacted Administrator (AD) Cheryl Whittle who authorized S1 to conduct the inspection and sign the report. AD Certification was confirmed during the visit. Census: 3 Residents were not present during the visit.

During this visit, LPA toured the facility inside & out Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathroom was clean and in good repair with faucets delivering hot water within required limits, grab bars and non-skid mats were in place. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in a hall closet. The First aid kit contained required items and hot water temperature read 110 degrees. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced by Jorgensen Co. on 2/27/2024. LPA conducted resident and staff file reviews. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit and found to be updated.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Safeguards for Cash Resources, Personal Property, and Valuables of Residents


LPA requested the following updated forms faxed to CCLD by 5/20/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E (2019), Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
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 2


Document Has Been Signed on 05/03/2024 12:19 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 CARE HOME #2
FACILITY NUMBER: 107200659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2024
Section Cited
CCR
80026(h)(1)

1
2
3
4
5
6
7
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources…(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger… accounting, with columns for income, disbursements and balance, for each client… This requirement was not as evidenced by:
1
2
3
4
5
6
7
AD has agreed to submit a written statement which will include that a financial audit was conducted, ledgers have been updated and are accurate and staff are trained on the facility procedures. This statement will be submitted by POC date.
8
9
10
11
12
13
14
Licensee did not ensure that an accurate record of resident's cash resources was accurately maintained. LPA reviewed the leger of resident R1 and R2.

This poses a potential health, safety or personal rights risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2