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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208867
Report Date: 10/06/2022
Date Signed: 10/06/2022 11:17:29 AM

Document Has Been Signed on 10/06/2022 11:17 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:CENTRAL STAR CRISIS RESIDENTIAL TREATMENTFACILITY NUMBER:
107208867
ADMINISTRATOR:GERARDO P.CERVANTESFACILITY TYPE:
772
ADDRESS:496 SOUTH BARTON AVETELEPHONE:
(559) 860-4422
CITY:FRESNOSTATE: CAZIP CODE:
93702
CAPACITY: 16CENSUS: 12DATE:
10/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Program Manager, Chantal WilliamsTIME COMPLETED:
11:31 AM
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On 10/06/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management deficiencies-visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Program Manager, Chantal Williams.

The purpose of this visit is to issue a deficiency for an illegal eviction. The facility reported that on 08/12/2022, R1 was asked to leave the facility due to inappropriate behavior. R1 was not given a 30 day written notice. R1 was discharged from the facility on 08/12/2022.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D.

An exit interview was conducted and a plan of correction was reviewed and developed with Program Manager. A copy of this report and appeals rights were discussed and provided to Program Manager, Chantal Williams whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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 10/06/2022 11:17 AM - It Cannot Be Edited


Created By: Alexandria Walton On 10/06/2022 at 11:01 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: CENTRAL STAR CRISIS RESIDENTIAL TREATMENT
FACILITY NUMBER: 107208867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
81068.5

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81068.5 EVICTION PROCEDURES: (a) The licensee shall be permitted to evict a client with 30 days' written notice... 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 81068.5 are met to the Fresno CCL office by the POC due date.
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Based on interviews and records review, the faciilty did not ensure the requirements for section 81068.5 were met when R1 was asked to leave and discharged from the facility on 08/12/2022. This poses a potential health and safety risk to person's 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: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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