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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150405408
Report Date: 09/12/2024
Date Signed: 09/12/2024 12:25:00 PM

Document Has Been Signed on 09/12/2024 12:25 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:MCCLELLAN BOARD & CARE FACILITYFACILITY NUMBER:
150405408
ADMINISTRATOR/
DIRECTOR:		GALICIA,RUDOLPHOFACILITY TYPE:
735
ADDRESS:4104 MILO STREETTELEPHONE:
(661) 834-5901
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 6CENSUS: 5DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Lead Yolanda BravoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst's (LPA)'s Shawna Doucette and Rachel Bruce arrived at the facility unannounced to conduct an Annual Inspection. LPA was granted entry by Staff Yolanda Bravo. Staff Yolanda Bravo contacted 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 did not meet 7 day non perishable and 2 day perishable. LPA took photos. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 85 degrees F. Facility was set at 73 F. Exterior tour conducted and garage fire exit was partially obstructed with boxes, linen rack and refrigerator/freezer . Side gate was observed to be self-latching.

Fire extinguisher serviced on 07/18/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm. Last fire drill conducted 7/31/2024. Facility did not have a disaster plan. All cleaning supplies are locked and secured in a cabinet in the garage.

LPA's reviewed resident and staff files which were complete.

An exit interview was conducted with the Supervisor Rosemary Bravo and a copy of this report with plans of correction and appeal rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 6
Document Has Been Signed on 09/12/2024 12:25 PM - It Cannot Be Edited


Created By: Shawna Doucette On 09/12/2024 at 11:27 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not having a disaster plan, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee agrees to submit a copy of completed disaster plan on the LIC 610D by POC due date 09/13/24.
Type A
Section Cited
CCR
8088(e)(1)
(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
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Based on [(observation) (interview) , the licensee did not comply with the section cited above in both resident bathrooms measured at 85F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee agrees to submit a photo of water measuring between 105 F to 120 F to meet this regulation by POC due date 09/13/24.
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: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/12/2024 12:25 PM - It Cannot Be Edited


Created By: Shawna Doucette On 09/12/2024 at 11:27 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (interview), the licensee did not comply with the section cited above in not having a 7 day non perishble and 2 day perishable food supply, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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Licensee agrees to submit photos of food supply for perishble and non perishable foods to meet the regulation by POC due date 09/13/24.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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