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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200413
Report Date: 12/01/2023
Date Signed: 12/01/2023 01:48:31 PM

Document Has Been Signed on 12/01/2023 01:48 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:RIVERSIDE RANCH, ASC TREATMENT GROUPFACILITY NUMBER:
157200413
ADMINISTRATOR:MORENO, ELANAFACILITY TYPE:
735
ADDRESS:18200 HIGHWAY 178TELEPHONE:
(661) 871-9697
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 51CENSUS: 47DATE:
12/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Administrator Laura VargasTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a case management inspection regarding an incident that occurred on 11/05/23. LPA met with Administrator Laura Vargas.

LPA reviewed C1's file. C1 AWOL'd on 11/05/23 at approximately 8 PM and was located on 11/08/23 at approximately 12 PM. Facility contacted Bakersfield PD Report #23-218215 immediately after C1 was noticed to be missing. C1 is currently under conservatorship and requires care and supervision.

Refer to 809D. Civil Penalty was issued.

A copy of this report was provided with plans of correction and appeal rights.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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 12/01/2023 01:48 PM - It Cannot Be Edited


Created By: Shawna Doucette On 12/01/2023 at 01:25 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: RIVERSIDE RANCH, ASC TREATMENT GROUP
FACILITY NUMBER: 157200413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
1569.312(a)

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1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced
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Plan of Correction POC Licensee agrees to conduct staff training on care and supervision of clients by POC due date 12/29/23.

Civil Penalty was issued.
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by: Licensee did not provide care and supervision to C1 who AWOL'd on 11/05/23 and was not located until 11/8/23 which poses an immediate health, safety, and or personal rights risk to clients 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023


LIC809 (FAS) - (06/04)
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