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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208901
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:22:39 PM

Document Has Been Signed on 07/06/2022 04:22 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:KAREN'S HOUSEFACILITY NUMBER:
107208901
ADMINISTRATOR:JACOBS, TEMIKA TRINAFACILITY TYPE:
735
ADDRESS:4744 W MENLO AVETELEPHONE:
(559) 275-3277
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 4CENSUS: 3DATE:
07/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Temika "Kym" JacobsTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit. LPA explained the purpose of the visit and met with Administrator Kym Jacobs.

The purpose of the Case Management visit is to follow up on Special Incident Reports (SIR) submitted. The reported incidents occurred on 6/1/22, 6/11/22 and 6/12/22 resulting in R1 Absent Without Official Leave (AWOL) from the facility.

During the visit, LPA interviewed AD. LPA conducted a record review of the staff schedule.
Since the time of the incidents, AD has hired 3 new staff members to provide additional coverage needs. R1 has been approved for daily 1:1 support hours from CVRC.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.


A copy of this report including Plan of Correction and Appeal Rights were emailed to
simplyeducated 01@yahoo.com. An exit interview was conducted with AD.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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 07/06/2022 04:22 PM - It Cannot Be Edited


Created By: Katie Brown On 07/06/2022 at 03:00 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: KAREN'S HOUSE
FACILITY NUMBER: 107208901

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/07/2022
Section Cited
CCR
80065(a)

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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement was not met as evidenced by:
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AD has agreed to provide a written statement which will include the plan and timeframe to implement an Elopement/AWOL procedure including staff inservice and dates. AD will also provide a calendar to show that the 1:1 support schedule for R1 and R2 7/7 - 8/31/22. Written statement and 1:1 calendar to be submitted to CCLD via email by 5PM 7/7/22.
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Licensee did not ensure facility personnel was able to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. R1 AWOL'd from the facility 6/1/22, 6/11/22 and 6/12/22 per the SIRs submitted by the Administrator.

This poses an immediate health & safety risk to persons in care.
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AD will submit Elopement/AWOL procedure and proof of staff training. Proof of training will include a staff sign in sheet and materials used. Procedure and training documents due by 5PM 7/14/22 via email.

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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: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022


LIC809 (FAS) - (06/04)
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