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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 08/31/2022
Date Signed: 08/31/2022 01:20:47 PM

Document Has Been Signed on 08/31/2022 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:DAMON HILLFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
08/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Misty Bryson, Program Director TIME COMPLETED:
01:30 PM
NARRATIVE
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On 08/31/22, Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Katherine Chattom Area Director was called and unable to attend meeting. Designate representative Misty Bryson Program Director arrived shortly.

The purpose of the today's visit is to address the incident report that was reported where staff was observed sleeping on client’s bed.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

An exit interview was conducted. A copy of this report and appeal rights was provided to Program Director.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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 08/31/2022 01:20 PM - It Cannot Be Edited


Created By: Mai Yang On 08/31/2022 at 12:42 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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80072(a)(1)

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80072 (a)(1) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights…(1)To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement was not met as evidenced by:
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Licensee stated that staff was retrained on Personal rights regulation. Licensee will submit documentation of training topics and attendance roster to the Fresno CCL office by due date.
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Based on interview conducted, Staff 1 (S1) was going through client 1’s (C1) drawer and was not feeling well. S1 laid down on client’s bed for approximately two minutes, which poses/posed a potential health and safety or personal rights risk to person 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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
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