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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150405408
Report Date: 09/14/2022
Date Signed: 09/09/2022 11:15:33 AM

Document Has Been Signed on 09/09/2022 11:15 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:MCCLELLAN BOARD & CARE FACILITYFACILITY NUMBER:
150405408
ADMINISTRATOR:GALICIA,RUDOLPHOFACILITY TYPE:
735
ADDRESS:4104 MILO STREETTELEPHONE:
(661) 834-5901
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 5DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:House Manager Rosemary Bravo TIME COMPLETED:
11:15 AM
NARRATIVE
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On 09/09/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Jessica Bravo. Administrator Rudolpho “Rudy” Galicia was contacted and stated unable to attend meeting. Administrator authorized caregiver to sign and received report. LPA conducted a facility tour with caregiver. House Manager Rosemary Bravo arrived shortly and conduct tour with LPA. There are currently two clients present during tour.

Upon entry facility staffs was observed with no face mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 05/02/22. LPA checked clients’ locked medications and observed a 30-day PPE supplies.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 1 shared client bed to be at least 6 feet apart and 3 single occupant room. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. LPA and House Manager observed chemical bottle under bathroom sink in the main bathroom unlock. LPA and House Manager observed cover lid for the back of toilet bowl missing in main bathroom. Cleaning supplies were stored and locked in chemical closet in garage.

The exterior tour was conducted. Outside free of obstruction and debris. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MCCLELLAN BOARD & CARE FACILITY
FACILITY NUMBER: 150405408
VISIT DATE: 09/14/2022
NARRATIVE
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A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 09/16/22. The following updated forms were requested: Lic 308, Lic 309 (if applicable), Lic 400, Lic 402, Lic 9282, transportation arrangement/procedure. LPA received copies of facility sketch, Lic 610D, Lic 9020 and Administrator certificate.

Administrator was informed that as COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/09/2022 11:15 AM - It Cannot Be Edited


Created By: Mai Yang On 09/09/2022 at 10:36 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: MCCLELLAN BOARD & CARE FACILITY
FACILITY NUMBER: 150405408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)

80087(g) Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Licensee did not comply with the section cited above, when LPA and House Manager observed at 09:44AM an opened Comet cleaning chemical bottle. Ajax bottle was found unlock under main bathroom sink accessible to clients which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 09/09/2022
Plan of Correction
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Staff immediately removed and lock Comet cleaning chemical bottle into lock chemical closet.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/09/2022 11:15 AM - It Cannot Be Edited


Created By: Mai Yang On 09/09/2022 at 10:38 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: MCCLELLAN BOARD & CARE FACILITY
FACILITY NUMBER: 150405408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at 09:47AM LPA and House Manager observed cover lid for the back of the toilet bowl missing in the main bathroom which can poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2022
Plan of Correction
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Licensee will replace or repair coverlid for back of toilet bowl. Proof of correction will be submitted to the CCL office by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022


LIC809 (FAS) - (06/04)
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