107201410-9-10-2025-24-AS-JLEL-DLE2ZK-20250910175029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201410
Report Date: 09/10/2025
Date Signed: 09/10/2025 05:50:59 PM

Document Has Been Signed on 09/10/2025 05:50 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	HASKINS RESIDENTIAL CARE		FACILITY NUMBER:	107201410
ADMINISTRATOR/ DIRECTOR:	HASKINS, DONALD		FACILITY TYPE:	735
ADDRESS:	1037 SOUTH CHESTNUT AVENUE		TELEPHONE:	(559) 453-6832
CITY:	FRESNO	STATE: CA	ZIP CODE:	93702
CAPACITY: 18		CENSUS: 11	DATE:	09/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator: Natalie Haskins		TIME VISIT/ INSPECTION COMPLETED:	06:00 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	On 9/10/2/2025, Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct a Required 1-year Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility. LPA met with Staff (S1) Erika Juarez. Administrator Natalie Haskins arrived shortly after LPA’s arrival. LPA conducted a tour of the facility with S1. During the inspection, the facility appeared clean and odor free and at a comfortable temperature. LPA toured the kitchen and observed 2-day supply of perishable. LPA did not observe 7-day supply of non-perishable food. LPA toured dining room and observed 3 dining tables for resident’s use. Two hallway closets observed with clean towels and linens. Knives/Sharps were observed to be inaccessible to residents in a kitchen drawer. Common areas were furnished and had adequate lighting and seating available for residents. LPA toured resident bedrooms. Bedrooms appeared clean and had the required furnishings and adequate lighting. Resident bathrooms appeared clean. LPA tested water temperature at a range of . Exterior tour conducted, all exits open and free of obstructions. Cleaning supplies observed to be locked in a cabinet in the outside laundry area. LPA reviewed a samples of residents files. Medication observed to be locked and inaccessible in the clinical office. LPA reviewed a sample of medications, Centrally Stored and MARs. LPA observed 1 prescribed medication initialed before required administration time. 1 medication was 1 over the required medication count. LPA reviewed staff and Administrators files. Fire extinguishers were observed to be current with a service date of 8/26/2025. Smoke detectors and carbon monoxide detectors tested and operational. Fire drill completed on 8/12/25.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HASKINS RESIDENTIAL CARE	FACILITY NUMBER: 107201410
	VISIT DATE: 09/10/2025

NARRATIVE

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Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 9/24/2025: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a printed copy was provided including appeal rights.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/10/2025 05:51 PM - It Cannot Be Edited

Created By: Jacques Leffall On 09/10/2025 at 05:31 PM

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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HASKINS RESIDENTIAL CARE	FACILITY NUMBER: 107201410
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(b)(6)(C)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 medications were initialed before administering and medication count was 1 day above required administering which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2025
	Plan of Correction
1 2 3 4	Licensee agrees for all staff to compete medication training and submit completion documents to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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.

	See Moua
NAME OF LICENSING PROGRAM MANAGER:

	Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025

LIC809 (FAS) - (06/04)

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