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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157200963
Report Date: 03/08/2024
Date Signed: 03/08/2024 05:51:49 PM

Document Has Been Signed on 03/08/2024 05:51 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:KERN ADULT PROGRAM, INC.FACILITY NUMBER:
157200963
ADMINISTRATOR:NORIEGA, JOHNFACILITY TYPE:
775
ADDRESS:2900 EYE ST.TELEPHONE:
(661) 323-4700
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY: 120CENSUS: 78DATE:
03/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Rhonda GlennTIME COMPLETED:
06:00 PM
NARRATIVE
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On 03/08/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct a case management visit based on a incident report received. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

Incident report states Client C1 AWOL'd from the day program on 01/24/24 and was located an hour and a half later, approximately 1/2 mile from facility. C1 was found to be safe and with local police. C1 was picked up by Administrator, who transported C1 to their home. LPA reviewed C1's Individual Program Plan (IPP), which states C1 has a history of elopement.

A deficiency is being cited based on LPA's record review and interview conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed with Administrator A copy of this report and appeal rights were discussed and left at the time of visit.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 03/08/2024 05:51 PM - It Cannot Be Edited


Created By: Lisa Salazar On 03/08/2024 at 02:24 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: KERN ADULT PROGRAM, INC.
FACILITY NUMBER: 157200963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
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. This requirement was not met as evidenced by LPA's records review of incident report dated 01/24/24.
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Licensee conducted staff training regarding C1's continous supervision. Licensee will ensure AWOL behaviors remain in the IPP. **POC Cleared**
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If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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