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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201351
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:17:34 PM

Document Has Been Signed on 03/12/2024 01:17 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:HOLDEN WAY HOMEFACILITY NUMBER:
157201351
ADMINISTRATOR:GLENN, RHONDAFACILITY TYPE:
735
ADDRESS:2201 HOLDEN WAYTELEPHONE:
(661) 832-3006
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY: 6CENSUS: DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:House Manager Joyce Brookins and Administrator Cheryl McCrawTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette conducted a Case Management to follow up on incident reports on 1/12/24 and 2/8/24. LPA was met by House Manager Joyce Brookins and discussed the purpose of the visit. Administrator Cheryl McCraw responded to the facility to assist with the case management.

LPA interviewed staff. LPA reviewed text message.

Based on interviews staff had a verbal altercation with C1 on 1/12/24.

Based on interviews and record review, there was a medication error for C2 on 2/9/24.

Refer to 809D for deficiencies.

An exit interview was conducted with House Manager and a copy of this report was provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 03/12/2024 01:17 PM - It Cannot Be Edited


Created By: Shawna Doucette On 03/12/2024 at 11:27 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: HOLDEN WAY HOME
FACILITY NUMBER: 157201351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a) Except for children’s residential facilities, 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, 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.
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Plan of Correction POC Licensee agrees to conduct staff training on abuse, reporting, personal rights and submit to licesning by POC due date 03/13/24
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This requirement was not met as evidenced by: Licensee did not ensure C1 was free of being riduculed and threatened by S1 which poses an immediate health safety and or personal rights risk to residents in care.
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Type A
03/13/2024
Section Cited
CCR80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: Licensee did not administer C2's medication
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Plan of Correction Licensee agrees to conduct a medication training for all staff and submit to licensing by POC due date 3/13/24
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on 2/9/24 which poses an immediate health safety and or personal rights risk to residents 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: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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