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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203204
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:20:21 PM


Document Has Been Signed on 06/28/2023 01:20 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:ALLEN RESIDENTIAL VISTA HOUSEFACILITY NUMBER:
107203204
ADMINISTRATOR:ALLEN, JOHNFACILITY TYPE:
735
ADDRESS:4591 N. VISTATELEPHONE:
(559) 277-0714
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 4DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Deshawn ReedTIME COMPLETED:
02:00 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 purpose of the visit with House Manager Deshawn Reed.

During this visit, LPA toured the facility inside & out which was found to be clean and odor free. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms which were clean. Resident hygiene supplies, linens and paper products were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPAs observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked, a medication audit was conducted. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed a self-releasing gate and windows have screens in good repair. Doors and passageways are unobstructed throughout the facility and outside. Smoke and Carbon Monoxide detectors present and in working order. Administrator certification expiration 12/3/2023.

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 was developed. A copy of this report and Appeal Rights were discussed and left with Deshawn Reed, whose signature on this form confirms receipt of these documents.

LPA requested the following updated forms faxed to CCLD by 7/5/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610D, Personnel Report (LIC 500), 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: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
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 06/28/2023 01:20 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: ALLEN RESIDENTIAL VISTA HOUSE
FACILITY NUMBER: 107203204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

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, which poses a potential health, safety or personal rights risk to persons in care. Administrator (AD) is unsure if an Infection Control Plan was submitted to CCLD and there was no record of the plan found in the facility at the time of the inspection.
POC Due Date: 07/13/2023
Plan of Correction
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Administrator (AD) has agreed to complete and submit an Infection Control Plan to CCLD by the POC due date.
Type B
Section Cited
CCR
80065(f)(4)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (4) Assistance with prescribed medications which are self-administered.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and medication audit conducted, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. PRN log does not include all required fields, MAR documentation including abbreviations and completeness, Centrally stored medication log to include start date.
POC Due Date: 07/13/2023
Plan of Correction
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Administrator has agreed to provide in-service to all staff who assist with resident medication. Inservice to include New PRN documentation log, complete MAR documentation, abbreviations to be used on MAR, complete and accurate Centrally stored log including medication card start date. A sign in sheet with name and signature of staff as well as the written facility procedure to be submitted to CCLD 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023
LIC809 (FAS) - (06/04)
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