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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:14:59 PM

Document Has Been Signed on 08/23/2022 02:14 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: 63DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Diedra Grigsby, Administrator
Vanessa Cortes, Regional Manager
Jason Martinez, Assistant Manager		TIME COMPLETED:
02:40 PM
NARRATIVE
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On 8/23/22 at 9:45 AM, Licensing Program Analyst (LPA) arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Administrator Diedra Grigsby, Regional Manager Vanessa Cortes, and Assistant Manager Jason Martinez.

LPA toured a sample of apartment units; one apartment on each floor of each apartment building. LPA did not observe any obstructions. Hand sanitizer was readily available to residents and visitors. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Administrator certificate is valid.

The following deficiencies were observed:

1. In apartment unit #211, the cabinet under the kitchen sink where chemicals were stored was unlocked and accessible. In apartment units #511, 521, 621, LPA observed blenders accessible on the kitchen counters with the blades installed. Shower cleaner solution was found accessible in bathtub and cabinet under bathroom sink in apartment unit #421.

2. In apartment units #122 and 414, the hot water measured 123.3 degrees F and 121.7 degrees F, respectively.

3. Apartment unit #612 did not have a carbon monoxide detector installed

4. Sharps in plastic bins were being kept in cabinet under kitchen sinks where chemicals were also stored in apartment units #511, 521, 612, 621, and 414.



Continue on LIC809-C.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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 5
Document Has Been Signed on 08/23/2022 02:14 PM - It Cannot Be Edited


Created By: Malia Thao On 08/23/2022 at 12:53 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: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. In apartment unit #211, the cabinet under the kitchen sink where chemicals were stored was unlocked and accessible; in apartment units #511, 521, 621, LPA observed blenders accessible on the kitchen counters with the blades installed; and shower cleaner solution was found accessible in bathtub and cabinet under bathroom sink in apartment unit #421, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Administrator immediately locked cabinet in apartment 211, immediately locked blender blades, and immediately locked shower cleaner. POC cleared during inspection.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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, the licensee did not comply with the section cited above. In apartment units #122 and 414, the hot water measured 123.3 degrees F and 121.7 degrees F, respectively, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Administrator will submit proof of hot water in apartment units #122 and 414 measuring within regulation to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/23/2022 02:14 PM - It Cannot Be Edited


Created By: Malia Thao On 08/23/2022 at 12:53 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: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Sharps in plastic bins were being kept in cabinet under kitchen sinks where chemicals were also stored in apartment units #521, 612, 621, and 414; apartment unit #511 observed with cheese grater in cabinet under kitchen sink where chemicals were also stored, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Administrator immediately removed the plastic bins with sharps in apartment units #521, 612, and 621, and cheese grater in apartment unit 511 to another inaccessible kitchen drawer. Administrator will submit proof of sharps for apartment unit #414 stored inaccessible in kitchen drawer where medication is also kept.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/23/2022 02:14 PM - It Cannot Be Edited


Created By: Malia Thao On 08/23/2022 at 01:12 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: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
§1503.2 Carbon monoxide detectors required; inspection

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed apartment unit #612 did not have a carbon monoxide detector installed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2022
Plan of Correction
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Administrator will submit proof of an operational and newly installed carbon monoxide detector for apartment unit #612 to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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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: 08/23/2022
NARRATIVE
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Continued from LIC809.

Deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D.


The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC610D (new revision)

Exit interview conducted. A copy of this report and a Plan of Correction was reviewed and developed with Administrator Diedra Grigsby, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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