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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201578
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:22:52 PM


Document Has Been Signed on 10/03/2023 03:22 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 #3FACILITY NUMBER:
107201578
ADMINISTRATOR:WHITTLE, CHERYL AFACILITY TYPE:
740
ADDRESS:4093 W. TERRACE AVENUETELEPHONE:
(559) 271-2152
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 2DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cheryl WhittleTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Katie Brown and Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Cheryl Whittle.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring 117 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Medications are centrally stored and locked. First aid kit contains required items. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the home including outdoors. Fire Extinguishers dated 3/20/23. Smoke and Carbon Monoxide detectors are present and in working order. LPA conducted resident and staff file reviews, interviews and a medication audit. Administrator certification expires 10/17/24. Emergency Disaster Plan and Infection Control Plan were reviewed during this visit.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Safeguards for Resident Cash, Personal Property, and Valuables, Maintenance and Operation and Storage Space.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.

LPA requested the following updated forms faxed to CCLD by 10/12/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage, Emergency Disaster Plan LIC610E.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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Document Has Been Signed on 10/03/2023 03:22 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 #3
FACILITY NUMBER: 107201578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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 which poses/posed a potential health, safety or personal rights risk to persons in care. Cleaning supplies were accessible in the laundry room and closet, scissors were observed in a cup on the kitchen counter.
POC Due Date: 10/12/2023
Plan of Correction
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AD has agreed to place a key pad door lock on the laundry room door. Inservice will be provided for staff on use of the door lock and inaccessibility of cleaning/disinfecting/laundry items and sharps like scissors. A copy of the in service sign in will be provided by email to CCLD by the POC date
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 10/12/2023
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2023 03:22 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 #3
FACILITY NUMBER: 107201578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(g)(1)
87217 Safeguards for Resident Cash, Personal Property, and Valuables (g) Each licensee shall maintain adequate safeguards and accurate records of cash resources…. (1) Records of residents' cash resources maintained as a drawing account shall include a ledger… for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 2 of 2 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident P&I logs were not available for review at the facility during the visit.
POC Due Date: 10/12/2023
Plan of Correction
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AD has agreed to submit the updated/current ledger to CCLD by the POC date via email.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed the refrigerator in the garage needs to be cleaned inside and out, tires in the front yard need to be disposed of and a patio chair needs to be thrown away due to damaged seat.
POC Due Date: 10/12/2023
Plan of Correction
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AD has agreed to provide photos to LPA to show that the above items have been cleaned and disposed of by the POC 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
LIC809 (FAS) - (06/04)
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