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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203963
Report Date: 04/16/2024
Date Signed: 04/16/2024 09:21:49 AM

Document Has Been Signed on 04/16/2024 09:21 AM - 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:KINDRED HOUSE #1FACILITY NUMBER:
107203963
ADMINISTRATOR/
DIRECTOR:		STREETS, SENAFACILITY TYPE:
735
ADDRESS:2396 S. POPPYTELEPHONE:
(559) 290-7623
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY: 6CENSUS: 4DATE:
04/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:24 AM
MET WITH:Licensee, Torrey HaynesTIME VISIT/
INSPECTION COMPLETED:
09:34 AM
NARRATIVE
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On 04/16/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Licensee, Torrey Haynes.

During the annual inspection conducted on 03/06/2024, LPA requested to review P&I records for all clients in care. Facility utilizes a bank account to store cash resources for clients and does not store cash in the facility. LPA requested for Licensee to submit copies of bank statements and an accounting ledger for each client in care. Upon review of records submitted, LPA found that the ending balance from accounting ledgers and bank statements were not accurate and resident cash resources were not handled by residents in care or facility staff. The facility did not maintain accurate records of accounts for 4 out of 4 residents in care, including maintaining copies of supporting receipts for purchases and bank records for transactions of cash withdrawn from the account. Records also revealed that cash resources for residents have been commingled with facility funds.

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

Exit interview conducted with Licensee and plans of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Licensee, Torrey Haynes, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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 04/16/2024 09:21 AM - It Cannot Be Edited


Created By: Alexandria Walton On 04/16/2024 at 08:38 AM
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: KINDRED HOUSE #1
FACILITY NUMBER: 107203963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
85072

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Personal Rights(b): The licensee shall insure that each client is accorded the following personal rights. (7) To possess and control his/her own cash resources… This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 85072(b)(7) are met to the Fresno CCL office by the POC due date. The written statement should include the facility’s plan to update the facility Plan of Operation to specify how resident cash resources will be safeguarded.
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Based on record review, the licensee did not ensure the requirements for the above section were met when 4 out of 4 residents did not have an accurate ending balance in the resident account that is managed by the facility and when residents did not have control over their cash resources, which is an immediate health and safety risk to persons in care.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2024 09:21 AM - It Cannot Be Edited


Created By: Alexandria Walton On 04/16/2024 at 08:44 AM
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: KINDRED HOUSE #1
FACILITY NUMBER: 107203963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/23/2024
Section Cited
CCR
87217(h)(2)

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(h) Each licensee shall maintain accurate records of accounts of cash resources… including… (2)Bank records for transactions of cash resources deposited in and drawn from the account specified in (i) below… This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detialing the steps the facility will take to ensure that the requriements for section 87217 are met to the Fresno CCL office by the POC due date.
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Based on record review, the Licensee did not maintain bank records for transactions of cash resoures that were withdrawn from the account, this is a potential health and safety risk to 4 out of 4 persons in care.
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Type B
04/23/2024
Section Cited
CCR87217(e)

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Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash... This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87217(e) are met to the Fresno CCL office.
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Based on record review, the Licensee did not ensure there requirements for section 87217(e) were met when 4 out of 4 resident funds were commingled with facility funds.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


LIC809 (FAS) - (06/04)
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