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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 01:05:34 PM

Document Has Been Signed on 11/30/2023 01:05 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: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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Program Director Stephanie BenavidezTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Program Director Stephanie Benavidez. LPA disclosed the purpose of the inspection and was granted entry into the facility by Program Director Stephanie Benavidez.

A tour of the facility was conducted with Program Director Stephanie Benavidez. The facility was set at 74 F temperature and free of passageway obstructions inside and outside. The water temperature was measured at 125.5 F.

Kitchen was toured. Cleaning supplies were in a locked storage cabinet in a locked storage room. Smoke detectors and carbon monoxide detectors were checked and operating. Facility is wired with sprinkler system. Fire extinguishers were charged and had service dates of 08/16/23. Fire drill was last completed on 10/19/23.

Client and staff records were reviewed. Current first aid and CPR were on file for staff.

Refer to 809D

An exit interview was conducted with the Program Manager and a copy of this report with plan of correction and appeal rights was provided.

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 01:05 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/30/2023 at 12:20 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: SVS BAKERSFIELD SOUTHWEST ADULT DAY PROGRAM
FACILITY NUMBER: 157200632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in water measuring at 125.5F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Licensee agrees to submit a photo of water temperature measuring between 105 to 120 F by POC due date 12/1/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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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