140908720-12-6-2023-24-AS-SDOE-CY9LPX-20231206075641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 140908720
Report Date: 12/05/2023
Date Signed: 12/06/2023 07:56:45 AM

Document Has Been Signed on 12/06/2023 07:56 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:	PROGRESS HOUSE - INYO CO. COM. MENTAL HEALTH SVCS.		FACILITY NUMBER:	140908720
ADMINISTRATOR:	MCKINZEY, GINA A		FACILITY TYPE:	735
ADDRESS:	536 N. SECOND STREET		TELEPHONE:	(760) 873-8572
CITY:	BISHOP	STATE: CA	ZIP CODE:	93514
CAPACITY: 12		CENSUS: 5	DATE:	12/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator Gina Mckinzey and House Supervisor Kelly Nugent		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with Administrator Gina Mckinzey and House Supervisor Kelly Nugent. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator.

A tour of the facility was conducted with the Administrator and House Supervisor. The residence was set at 70 F temperature and free of passageway obstructions inside and outside. Facility water temperature measured at 120 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication room. Cleaning supplies were in a locked outdoor shed. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 04/21/23. Facility last conducted fire drill on 08/7/23.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. Current first aid and CPR were reviewed.

Refer to 809d

A an exit interview was conducted and a copy of this report was provided with plan of correction and appeal rights.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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 12/06/2023 07:56 AM - It Cannot Be Edited

Created By: Shawna Doucette On 12/05/2023 at 03:21 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: PROGRESS HOUSE - INYO CO. COM. MENTAL HEALTH SVCS.	FACILITY NUMBER: 140908720
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80068(a)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in C1 not having a signed admissions agreement in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a signed admissions agreement for C1 by POC due date 12/8/23.

Type B

Section Cited

CCR

85068.2(b)(1)(C)

Needs and Services Plan

(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in C1 not having a physicians report in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit an LIC602 physicians report for C1 by POC due date 12/8/23.

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:

Shawna Doucette

LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC809 (FAS) - (06/04)

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