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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157200963
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:15:05 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
07/18/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220718101850
FACILITY NAME:KERN ADULT PROGRAM, INC.FACILITY NUMBER:
157200963
ADMINISTRATOR:GLENN, RHONDAFACILITY TYPE:
775
ADDRESS:2900 EYE ST.TELEPHONE:
(661) 323-4700
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:120CENSUS: 89DATE:
10/05/2022
UNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Administrator, Rhonda GlenTIME COMPLETED:
01:16 PM
ALLEGATION(S):
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A resident passed away at the facility.
INVESTIGATION FINDINGS:
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On 10/5/22 Licensing Program Analyst (LPA) M. Garza arrived at facility unannounced to deliver findings on the allegation listed above. LPA introduced self, was COVID pre-screened and permitted entry into the facility. LPA met with Administrator, Rhonda Glenn and explained reason for visit. LPA completed a tour of the facility and completed a health and safety check on residents in care. Residents observed in activity rooms.

During investigation the Department conducted interviews, reviewed medical records and a copy of client file. Client required 1:1 supervision. Facility failed to properly care and provide 1:1 supervision. Client choked and subsequently passed while in care.

Based on this, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiency is being cited on the attached LIC 9099D. An immediate civil penalty of $500 is being assessed.

CONT...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
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-20220718101850
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: KERN ADULT PROGRAM, INC.
FACILITY NUMBER: 157200963
VISIT DATE: 10/05/2022
NARRATIVE
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CONT...

The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report to the facility, if any.

Exit interview completed with Administrator, Rhonda Glenn. A copy of this report, deficiency and appeal rights were provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20220718101850
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: KERN ADULT PROGRAM, INC.
FACILITY NUMBER: 157200963
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited
CCR
82078(a)
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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.


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Administrator states they will provide a plan of correction in writing to CCL by POC date. It will state "the program will access all clients that will be entering to the program if they need a 1:1. If they do they will not be accepting the client until they receive the 1:1 authorization from regional center. Training will be completed with all staff for procedure on personalized reports for all clients. A copy of the training material and sign in sheet to be provided to CCL by POC date.
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This requirement was not met as evidence by: the Departments interviews and records reviewed showing the facility failed to provide 1:1 care for clients behaviors resulting in client passing. This 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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3