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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201578
Report Date: 09/08/2025
Date Signed: 09/08/2025 03:01:16 PM

Document Has Been Signed on 09/08/2025 03:01 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/
DIRECTOR:		WHITTLE, CHERYL AFACILITY TYPE:
740
ADDRESS:4093 W. TERRACE AVENUETELEPHONE:
(559) 271-2152
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 1DATE:
09/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Chris WilliamsTIME VISIT/
INSPECTION COMPLETED:
03:09 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Facility Designee Chris Williams.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained the required equipment, furnishings and lighting. LPA observed required items in bathrooms with faucets delivering hot water. LPA observed hygiene items, paper products, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed the required food supply. Medications are centrally stored in a hall closet. Cleaning/disinfecting supplies and chemicals are locked. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit contained required items.

LPA walked outdoors to find the grounds well-kept with clear walkways. Fire extinguishers were found to be charged and serviced 1/9/24 by Jorgensen Fire Co. LPA conducted resident and staff file reviews and a medication audit. Infection Control and Emergency/Disaster procedures were reviewed.



Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 9/23/2025- Emergency Disaster Plan (Lic610D), Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage, Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402),
NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Katie Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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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Document Has Been Signed on 09/08/2025 03:01 PM - It Cannot Be Edited


Created By: Katie Brown On 09/08/2025 at 02:28 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: WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER: 107201578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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. LPA observed the following which require repair or replacement - Blinds on kitchen door are damaged, the wall in bedroom 2 needs repair on previous damage, the back yard fence is leaning and needs stabelization.
POC Due Date: 09/23/2025
Plan of Correction
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AD has agreed to replace kitchen blinds, repair the wall in bedroom 2 and stabelize the fence in the backyard. Pictures of these repairs will be emailed to CCL by poc date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review th,e licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. A record of centrally stored prescription medications for R1 is not maintained for current medications.
POC Due Date: 09/23/2025
Plan of Correction
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AD has agreed to provide staff in-service on the requirements of centrally stored prescription medications. Proof of training as well as a sign in sheet will be submitted to CCL by 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.
Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Katie Brown
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2025


LIC809 (FAS) - (06/04)
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