<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150405408
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:12:48 AM

Document Has Been Signed on 10/25/2023 11:12 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:
10/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee Virginia MCclellan and Supervisor Rosemary Bravo and Staff Yolanda BravoTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct an Annual Inspection. LPA was granted entry by Staff Yolanda Bravo. Staff Yolanda Bravo contacted Licensee Virginia Mcclellan and Supervisor Rosemary Bravo who responded to the facility to assist with the visit.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 124.6 degrees F. Facility was set at 75 F. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 07/06/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm. Last fire drill conducted 10/02/2023. All cleaning supplies are locked and secured in a cabinet in the garage.

An exit interview was conducted with the Supervisor Rosemary Bravo and a copy of this report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 10/25/2023 11:12 AM - It Cannot Be Edited


Created By: Shawna Doucette On 10/25/2023 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: MCCLELLAN BOARD & CARE FACILITY
FACILITY NUMBER: 150405408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in Licensee did not have water measured between 105 F and 120 F. Water was measured at 124.6 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
1
2
3
4
Licensee agrees to submit a photo of water being in between 105 F and 120 F by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4