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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206747
Report Date: 01/30/2023
Date Signed: 01/30/2023 04:03:58 PM

Document Has Been Signed on 01/30/2023 04:03 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:D & D RESIDENTIAL INC.FACILITY NUMBER:
107206747
ADMINISTRATOR:SMITH, DWAYNE E.FACILITY TYPE:
735
ADDRESS:5741 N. KATY LANETELEPHONE:
(559) 369-7001
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 4CENSUS: 4DATE:
01/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:08 PM
MET WITH:Dwayne SmithTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a case management-incident visit in conjunction with the facility Annual Inspection LPA met with and explained the purpose of the visit with Administrator (AD) Dwayne Smith.

The facility submitted Special Incident Reports (SIR) dated 1/9/23 and 1/18/23 reporting that Resident (R1) was experiencing a behavioral emergency resulting in hospitalization. During the visit, LPA toured the facility conducted interviews and a record review of R1's file.


During the facility tour, LPA observed that the blinds, windowsills, doors and walls throughout the facility need to be cleaned. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-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 Dwayne Smith, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2023
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 01/30/2023 04:03 PM - It Cannot Be Edited


Created By: Katie Brown On 01/30/2023 at 03:29 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: D & D RESIDENTIAL INC.
FACILITY NUMBER: 107206747

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited
CCR
80087(a)

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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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Adminirator (AD) agrees to revise the current house cleaning procedure and assignments. A copy of the revised procedure/plan will be submitted to CCLD along with a staff training inservice sign in. The sign in sheet will include the name and description of the inservice, name and signatures of all staff as well as trainers
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Licensee did not ensure that the facility was clean and sanitary. LPA observed window blinds, sills, walls and light switches throughout the home that require cleaning.

This poses a potential haelth, safety or personal rights risk to persons in care.
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name and timing. These documents will be emailed to LPA by the due date.

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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 Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023


LIC809 (FAS) - (06/04)
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