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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200632
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:28:36 PM

Document Has Been Signed on 11/06/2024 02:28 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:SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAMFACILITY NUMBER:
157200632
ADMINISTRATOR/
DIRECTOR:		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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Regional Director Latisha AlbrittonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shawna Doucette arrived unannounced to deliver findings complaint investigation. During the course of the investigation deficiencies were observed. LPA was granted entry by Staff Xinia Ulloa. LPA met with Regional Directior Latisha Albritton.

LPA requested a copy of C2's admissions agreement as part of the investigation for complaint 24-AS-2024072312010. Regional Director was unable to provide a copy of C2's Admissions Agreement.

Refer to 809D.

A copy of this report along with plan of correction and appeal rights were provided to the Regional Director.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/06/2024 02:28 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/06/2024 at 11:42 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2024
Section Cited
CCR
82068(a)

1
2
3
4
5
6
7

82068 Admission Agreements (a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any. This requirement was not met as evidenced by: Licensee did not
1
2
3
4
5
6
7
Plan of Correction POC Licensee agrees to submit a written understanding of how this regulation will be met in the future and will submit by POC due date 11/08/24.
8
9
10
11
12
13
14
have an admissions agreement for C2 which poses a potential 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 2