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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 12:48:09 PM

Document Has Been Signed on 09/12/2024 12:48 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:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:House Manager Rosemary BravoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts LPA's Shawna Doucette and Rachel Bruce arrived at the facility unannounced to conduct a Case Management for an incident that occurred on 8/15/24 involving R1 missing a medication.

LPA's interviewed staff. R1's medication was not refilled in a timely manner and was missed on 8/15/24. Facility contacted the doctor and was able to obtain and administer the medication on 8/16/24.

Refer to 809d

An exit interview was conducted with House Manager and appeal right and plan of corrections 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)
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Document Has Been Signed on 09/12/2024 12:48 PM - It Cannot Be Edited


Created By: Shawna Doucette On 09/12/2024 at 12:34 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: MCCLELLAN BOARD & CARE FACILITY
FACILITY NUMBER: 150405408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as R1 did not receive his medication causing R1 to miss
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POC Licensee agrees to come up with a plan to ensure medications are refilled in a timely manner by POC due date 09/13/24.
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the medication on 08/15/24, which poses an immediate health safety and personal rights risk to residents in care.
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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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