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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201351
Report Date: 12/13/2023
Date Signed: 12/13/2023 05:24:03 PM

Document Has Been Signed on 12/13/2023 05:24 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: 5DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Administrator Cheryl McCraw and House Manager Glinda BrookinsTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced and conducted an Annual Inspection on this date. LPA was met by House Manager Glinda Brookins. LPA contacted Administrator Cheryl McCraw via telephone, who responded to the facility to assist with the visit.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food.

Resident rooms checked. LPA observed a wall dividing two of the bedrooms for client privacy which was not fire cleared for either room. LPA observed an adequate supply of linen. Hot water measured at 110.1 degrees F. Facility was set at 70 F.

Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 04/10/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 12/07/2023. All cleaning supplies are locked in a cabinet in the in the dining room. Facility did not have a disaster plan.

Refer to 809D. Civil Penalty issued.

An exit interview was conducted with the Administrator and a copy of this report with plans of correction and appeal rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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 12/13/2023 05:24 PM - It Cannot Be Edited


Created By: Shawna Doucette On 12/13/2023 at 01:19 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: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
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:
Deficient Practice Statement
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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 persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee agrees submit new fire clearance to licensing by POC due date 12/14/23.
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: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/13/2023 05:24 PM - It Cannot Be Edited


Created By: Shawna Doucette On 12/13/2023 at 01:19 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: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(b)(8)
Plan of Operation
(8) A sketch of the grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation areas and other space used by the clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in facility not having a facility sketch in facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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Licensee agrees to submit facility sketch to licensing by POC due date 12/14/23.
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in facility did not have a disaster plan at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/18/2023
Plan of Correction
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Licensee agrees to submit emergency disaster plan to licensing by POC due date 12/18/23.
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: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
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