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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801279
Report Date: 02/25/2022
Date Signed: 03/02/2022 07:18:41 AM


Document Has Been Signed on 03/02/2022 07:18 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:GABLES, THEFACILITY NUMBER:
155801279
ADMINISTRATOR:ESTHER MAESEFACILITY TYPE:
740
ADDRESS:903 SPIRIT LAKE DRIVETELEPHONE:
(661) 213-3927
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 3DATE:
02/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Sally Jackson, CaregiverTIME COMPLETED:
05:15 PM
NARRATIVE
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On 02/25/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a Health & Safety check on residents is care. LPA was greeted by Staff S1, stated the purpose of the and was allowed entry into the facility. LPA toured the facility and observed a 5 bedroom, 3 bathroom house.

LPA observed 3 out of 3 residents in care. Resident R1 and Resident R2 were watching TV in the living room, accompanied by family members. Resident R3, was in the living room with visiting with family.

Facility has hospice waiver for two. 2 out of 3 residents are receiving Hospice Care, LPA observed hospice care plans on file for R1 and R2.

LPA reviewed resident files with current LIC 602 physician's report. Fire extinguishers dated 08/26/21 and operating smoke detectors were observed. Current Emergency Disaster plan is posted along with other require posting.

The Administrator on file recently retired leaving no Administrator on record at this time. Stephanie Haro, Administrator certificate #6049449740 is completing the paperwork process to become the Administrator. This poses a potential risk to resident's in care.

Staff S1 is fingerprint cleared, however, S1 is not associated to the facility. This poses an immediate risk to residents in care.

(continued on 809-C)
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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 03/02/2022 07:18 AM - It Cannot Be Edited

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: GABLES, THE
FACILITY NUMBER: 155801279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2022
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by LPA's records review of the current facility roster. S1 is not associated to the facility.
* Civil Penalty is being assessed.*
Type B
03/25/2022
Section Cited

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87405 Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

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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 HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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: GABLES, THE
FACILITY NUMBER: 155801279
VISIT DATE: 02/25/2022
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(continued from 809)

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809-D.

Executive Secretary to Licensee has given verbal authorization for S1 to sign the report. Exit interview conducted and plan of correction was developed. Appeal rights and copy of the report were given at the time of visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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