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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 01/04/2024
Date Signed: 01/05/2024 08:59:00 AM

Document Has Been Signed on 01/05/2024 08:59 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:CENTRE VILLAGEFACILITY NUMBER:
150406456
ADMINISTRATOR:RODRIGUEZ LOPEZ, NORAFACILITY TYPE:
735
ADDRESS:2500 GOSFORD ROADTELEPHONE:
(661) 836-2500
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 76CENSUS: 56DATE:
01/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Administrator, Nora RodriguezTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Darius Williams conducted a Case Management (CM) in regards to medication error reports from the facility dated 12/13/2023, 12/14/2023, and 12/15/2023. LPA met with Administrator Nora Rodriguez and discussed the purpose of the visit.

Administrator reported three separate staff on three separate occasions, provided three separate clients with too much dosage of medication.

Medical services or pharmacy were contacted on each occasion.

Administrator reported the Staff involved are receiving remedial training and supervision in medication administration.

Additionally, the Administrator is providing mass training to all care providers on 1/8/2024.

Based on interview and records, a deficiency is being cited on the attached LIC 809D page.

Plan of correction was review and discussed with the Administrator.

An exit interview was conducted and a copy of this report and appeal rights will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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 01/05/2024 08:59 AM - It Cannot Be Edited


Created By: Darius Williams On 01/04/2024 at 01:34 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited
CCR
80075(b)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met evident by:
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Administrator agreed to provide an action plan regarding remedial training for three staff. Administrator will provide the plan to the Department by POC due date 1/5/2024.
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The Licensee did not ensure 3 of 56 clients received, appropriate dosage of medication, which poses an immediate health and safety risk to persons 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:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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