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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 01:53:22 PM

Document Has Been Signed on 03/12/2024 01:53 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: 6DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:House Manager Joyce BrookinsTIME COMPLETED:
02:15 PM
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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. During the course of the visit LPA observed a deficiency that was previously cited and has not been corrected. LPA met with House Manager Joyce Brookins and discussed the purpose of the visit.

LPA observed a wall dividing two of the bedrooms for client privacy which was not fire cleared for either room. LPA cited for this violation during an annual on 12/13/23. LPA did not receive the plan of correction and observed the walls to still be up dividing the room.

See 809d for deficiency.

A copy of this report with plan of correction and appeal rights were 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 01:53 PM - It Cannot Be Edited


Created By: Shawna Doucette On 03/12/2024 at 01:44 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: 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
80020(a)

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80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Plan of Correction POC Licensee agrees to submit the LIC200 and facility sketch by poc due date 3/13/24.
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Based on observation, the licensee did not comply with the section cited above in two client bedrooms have a wall dividing each room without a fire clearance, which poses an immediate health, safety or personal rights risk to person
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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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