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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200632
Report Date: 11/30/2023
Date Signed: 11/30/2023 11:06:38 AM

Document Has Been Signed on 11/30/2023 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: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: 78DATE:
11/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Program Director Stephanie BenavidezTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility to conduct a case management inspection regarding an incident that occurred on 09/22/23. LPA met with Program Director Stephanie Benavidez.

LPA conducted interviews and obtained copies of facility's investigation with signed statements. LPA reviewed the video and audio of S3 intimidating and threatening C1. S2 and S3 were terminated. Program Director conducted a training on client rights and mandated reporting.

Refer to 809d.


A copy of this report was provided to Program Director Stephanie Benavidez, with plan of correction and appeal rights. POC cleared during visit.


SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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 11/30/2023 11:06 AM - It Cannot Be Edited


Created By: Shawna Doucette On 11/30/2023 at 10:36 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: SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAM
FACILITY NUMBER: 157200632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2023
Section Cited
CCR
82072(a)(3)

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82072 Personal Rights (a) 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,

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Plan of Correction POC Licensee agrees to conduct staff training on client rights and mandated reporting by POC due date. POC cleared during visit.
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 coercion, threat, mental abuse, or other 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 prevent C1 from being threatened or indimidated by S3 on 09/22/23 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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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