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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:56:38 AM

Document Has Been Signed on 03/07/2024 11:56 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: 64DATE:
03/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Administrator, Nora RodriguezLopezTIME COMPLETED:
12:01 PM
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Licensing Program Analyst (LPA) Darius Williams conducted a follow up Case Management visit from 2/22/2024, regarding a manual restraint being used. LPA met with Nora RodriguezLopez and discussed the purpose of the visit.

According to a record review conducted at the Fresno Regional Office, the facilities Emergency Intervention Plan only mentions a restraint intervention program called PART. According to the facility PRO-ACT Instructor the intervention program used is PRO-ACT. The Administrator provided a copy of the facilities current Emergency Intervention plan however it has not been provided to the Department for review and approval. Upon further review of the plan provided by the Administrator, LPA noticed it did not meet the regulatory requirements. The facilities current emergency intervention plan is not accurate and requires update and approval from the Department.

According to facility records, 5 of 5 staff have received initial PRO-ACT training. However, they do not have the required annual 6 hours of training.

Finally, according to the PRO-ACT curriculum provided by the instructor, LPA observed a seating restraint and wall restraint. LPA did not observe a prone restraint authorized in the program curriculum.

The Administrator reported she will send out an immediate notice informing employees that MANUAL RESTRAINTS CAN NOT BE USED until the Emergency Intervention Plan has been updated to reflect their new curriculum and has been approved by the Department, and staff identified to use intervention techniques have received 6 hours of annual training.

*Continued on LIC 809C*
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CENTRE VILLAGE
FACILITY NUMBER: 150406456
VISIT DATE: 03/07/2024
NARRATIVE
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Based on LPA's interviews and record reviews a deficiency is being cited on the attached LIC 809D pages.

A plan of correction was discussed and reviewed with the Administrator.

A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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Document Has Been Signed on 03/07/2024 11:56 AM - It Cannot Be Edited


Created By: Darius Williams On 03/07/2024 at 11:23 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
CCR
85122(d)(3)(A)(1)

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1.Prone containment shall only be used in compliance with Section 1180.4(f) of the Health and Safety Code.

This requirement was not met evident by:
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Administrator is immediately sending memo to all employees that the facility is not using prone restraint as an emergency intervention technique. Administrator agreed to provide memo to the Department by POC due date 3/8/2024.
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The Licensee did not ensure that staff were trained and authorized to used prone restraint on 1 client, which poses and immediate health and safety risk to persons in care.
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Type B
03/13/2024
Section Cited
CCR85122(a)

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(a) The applicant or licensee shall be responsible to ensure an Emergency Intervention Plan is developed and approved by the Department prior to the use of manual restraint or seclusion,...

This requirment was not met evident by:
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Administrator agreed to provide an updated Emergency Intervention Plan for review to the Department by POC due date of 3/13/2024.
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The Licensee did not ensure their current Emergency Intervention Plan was approved by the Department, which poses a potential 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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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Document Has Been Signed on 03/07/2024 11:56 AM - It Cannot Be Edited


Created By: Darius Williams On 03/07/2024 at 11:32 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: CENTRE VILLAGE
FACILITY NUMBER: 150406456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
85165(b)(3)

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(3) Staff shall have a minimum of 6 hours of annual refresher training following the initial training certification. The provisions specified in Section 85165 (c)-(e) and, (g) shall also apply to this training.

This requirement was not met evident by:
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Administrator agreed to provide 6 hours of restraint training to 4 staff by POC due date of 3/15/2024. Additionally, a plan will be provided regarding training additional staff.
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The licensee did not ensure that 5 of 5 staff received 6 hours of annual training regarding manual restraint, which poses a potential health and safety risk of 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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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