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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206803
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:23:47 PM

Document Has Been Signed on 07/27/2022 01:23 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:STEPHEN HOUSEFACILITY NUMBER:
107206803
ADMINISTRATOR:SUNDARI SUSAN KENDAKURFACILITY TYPE:
740
ADDRESS:1824 DONNER AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Luijean De Castro AbraganTIME COMPLETED:
01:40 PM
NARRATIVE
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On 7/27/22, Licensing Program Analyst (LPA) M. Medina arrived unannounced on another matter. LPA met with Luijean De Castro Abragan, Care Coordinator and explained the purpose of the visit.

During the Department’s complaint investigation, it was determined staff member Staff 1 (S1) and Staff 2 (S2) were fingerprint cleared but not associated to work at facility. This was confirmed by interviews conducted and Licensing Information Systems records. Care Coordinator stated paperwork will be submitted to Department to resolve fingerprint association issue. Both staff were removed from facility during Case Management visit.

Deficiency cited on the attached 809 D per the California Code of Regulations, Title 22. The Department is assessing an immediate CIVIL Penalty in the amount of $500.00 per staff person.

Exit interview conducted. Appeal rights provided.

A copy of this report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/27/2022 01:23 PM - It Cannot Be Edited


Created By: Melinda Medina On 07/27/2022 at 12:59 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: STEPHEN HOUSE
FACILITY NUMBER: 107206803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

***This was not met as evidenced
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Licensee to submit required documentation to associate S1 and S2 to facility by POC due date. Staff will not work in facility until fingerprint transfer association is completed by Department.
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by LPA observed that S1 and S2 were fingerprint cleared and not associated to facility by review of deparment facility personnel report summary
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CIVIL PENALTY ASSESSED

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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:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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