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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150406456
Report Date: 02/22/2024
Date Signed: 02/22/2024 11:06:36 AM

Document Has Been Signed on 02/22/2024 11:06 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: 60DATE:
02/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Regional Residential Manager, Vannessa CortezTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Darius Williams conducted a Case Management visit in response to a report sent to the Department by the facility, in regards to a manual restraint. LPA Williams met with Regional Residential Manager, Vanessa Cortez.

LPA Williams conducted interviews, reviewed report, facility documents, and Resident 1 file.

LPA requested the following documents/information be provided to the Department by 2/28/24 :

- Statements/report from individuals involved in restraint.
- Pro Act certifications from individuals involved in restraints.
- Everyday behavior tools for Resident 1
- Pro Act restraint program taught by Instructor 2.

Due to insufficient, information available at this time further investigation is required.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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