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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200413
Report Date: 03/26/2024
Date Signed: 03/28/2024 08:27:58 AM

Document Has Been Signed on 03/28/2024 08:27 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: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: 48DATE:
03/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Assistant Administrator Brian Nelson and Administrator Laura VargasTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to follow up on a case management that occurred on 1/23/24. LPA met with Assistant Administrator Brian Nelson and Administrator Laura Vargas.

LPA interviewed staff and residents. LPA obtained copies of R2's medical records. Refer to Bakersfield Police Department 24-16947.

After conducting interviews, the incident occurred about 8:15 AM. Staff did not take R2 to the hospital until 9- 9:30 AM. Hospital records show appointment time of 10:30 AM.


Refer to 809d. Civil Penalty was issued.

A copy of this report along with appeal rights and plans of correction was provided to Administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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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Document Has Been Signed on 03/28/2024 08:27 AM - It Cannot Be Edited


Created By: Shawna Doucette On 03/26/2024 at 10:39 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: RIVERSIDE RANCH, ASC TREATMENT GROUP
FACILITY NUMBER: 157200413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other \
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Plan of Correction POC Licensee agrees to submit an agenda by 3/27/24. Licensee agrees to provide training to staff on personal rights by POC due date 4/26/24.
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actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This was not met as evidenced by Licensee did not protect R1 from injuring R2 which poses and immediate health, safety and or personal rights risk to residents in care.
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Type A
03/27/2024
Section Cited
CCR80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. Thise requurement was not met as evidenced by S1 and S2 not following company policy to not put residents in lines to prevent altercations between residents and S1 not descalating the verbal altercation which resulted in R1 injuring R2 where R2 was hospitalized which poses and immediate health safety and or personal rights risk to residents in care.
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Plan of Correction POC Licensee agrees to submit an agenda on care and supervision staff training by 03/27/24 submit proof of training for all staff by 04/27/24.
Civil Penalty was issued.
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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: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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