<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157200632
Report Date: 11/06/2024
Date Signed: 11/06/2024 12:05:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240723120101
FACILITY NAME:SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAMFACILITY NUMBER:
157200632
ADMINISTRATOR:BENAVIDEZ, STEPHANIEFACILITY TYPE:
775
ADDRESS:4705 NEW HORIZON BLVD, STE 12TELEPHONE:
(661) 241-6758
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:90CENSUS: 50DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Regional Director Latisha AlbrittonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate care and supervision to a client
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to deliver findings complaint investigation. LPA was granted entry by Staff Xinia Ulloa. LPA met with Regional Directior Latisha Albritton.

LPA reviewed C2's IPP and LIC 602. Facility was unable to provide a copy of the Admissions Agreement for C2.

Based on interviews and records review, C2's IPP states client requires constant supervision due to safety concerns. C2's medical records indicate C2 obtained a fracture.

Based on the Departments interviews and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D.
A copy of this report along with plan of correction and appeal rights were provided to the Regional Director.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20240723120101
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAM
FACILITY NUMBER: 157200632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2024
Section Cited
CCR
82078(a)
1
2
3
4
5
6
7

82078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision necessary to meet the client's needs and all services specified in the admission agreement. This requirement was not met as evidenced
1
2
3
4
5
6
7

Plan of Correction Licensee agrees to conduct a training for all staff on care and supervision by POC due date 11/08/24. POC cleared during visit. Training conducted on 7/26/24 .
8
9
10
11
12
13
14
by: Licensee did not provide Care and Supervision when C2 fell obtaining a fracture while on an outing with S1, which poses an immediate health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240723120101

FACILITY NAME:SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAMFACILITY NUMBER:
157200632
ADMINISTRATOR:BENAVIDEZ, STEPHANIEFACILITY TYPE:
775
ADDRESS:4705 NEW HORIZON BLVD, STE 12TELEPHONE:
(661) 241-6758
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:90CENSUS: 50DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Regional Director Latisha AlbrittonTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly report an incident involving a client
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to deliver findings complaint investigation. LPA was granted entry by Staff Xinia Ulloa. LPA met with Regional Directior Latisha Albritton.

LPA interviewed staff and clients. LPA reviewed SIR.

Based on interviews and review of SIR, Facility submitted SIR once made aware of the situation, which was within the required time frame. C2 did not report the incident to staff. Regional Director was made aware of the incident by C2's authorized representative.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

A copy of this report was provided to the Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3