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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 12/09/2021
Date Signed: 12/09/2021 05:35:08 PM

Document Has Been Signed on 12/09/2021 05:35 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:CENTRE VILLAGEFACILITY NUMBER:
150406456
ADMINISTRATOR:GRIGSBY, DIEDRAFACILITY TYPE:
735
ADDRESS:2500 GOSFORD ROADTELEPHONE:
(661) 836-2500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 76CENSUS: DATE:
12/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Diedra Grigsby, Administrator
Jason Martinez, Assistant Manager		TIME COMPLETED:
03:15 PM
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On 12/9/21 at 12:30 PM, Licensing Program Analysts (LPAs) Malia Thao and Mary Garza arrived unannounced to conduct a case management - incident inspection. LPAs explained reason for inspection and was granted entry. LPAs met with Administrator Diedra Grigsby and Assistant Manager Jason Martinez.

Facility submitted two incident reports to CCL on 11/3/21. One incident involved R1 being left at the store while grocery shopping with staff. Second incident reported R2 was given a double dose of medication. LPAs reviewed records and conducted interviews.

The following deficiencies observed:
1. R1 walked away from group during a grocery outing. R1's physician report states R1 can not leave the facility unassisted.
2. R2 was given a double dose of medication Bethanechol 10 mg at 8am. S3 administered both doses of medication for 8am and 2pm at the 8am medication administration.

Deficiencies are being cited based on LPAs' interviews and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and emailed to Administrator Diedra Grigsby with "Read Receipt" to confirm receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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 12/09/2021 05:35 PM - It Cannot Be Edited


Created By: Malia Thao On 12/09/2021 at 01:59 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/10/2021
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:

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Administrator states she will submit an in-service training of the facility's program and proximity training for S1 and S2 to CCL by POC due date.
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R1 walked away from group during a grocery outing. R1's physician report states R1 can not leave the facility unassisted. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
12/09/2021
Section Cited
CCR80075(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 is not met as evidenced by:
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Administrator provided a copy of the in-service medication administration training given to S3 on 10/30/21 after incident occurred. POC cleared.
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R2 was given a double dose of medication Bethanechol 10 mg at 8am. S3 administered both doses of medication for 8am and 2pm at the 8am medication administration. This poses an immediate health 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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