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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201351
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:38:32 PM

Document Has Been Signed on 06/09/2022 03:38 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:
06/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Cheryl McCrawTIME COMPLETED:
12:30 PM
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Licensing Program Analyst LPA conducted a Case Management to follow up on an incident reports on 10/26/21 and 2/18/22. LPA was met by Staff James Simpkins and discussed the purpose of the visit. Administrator Cheryl McCraw responded to the facility to assist with the case management.

LPA reviewed records showing that C1 did not receive the correct medication.on 10/21/21.

LPA interviewed staff for an incident occurred on 2/18/22 regarding a client being left unsupervised. It was found the day program dropped the client off 30 minutes prior to normal drop off time. Facility staff normally arrives to facility 20 minutes prior to clients arrival. Facility was not notified by day program that client was going to be dropped off early.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D.

An exit interview was conducted with Administrator Cheryl McCraw a copy of this report with Plans of Corrections and appeal rights was provided
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 06/09/2022 03:38 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/09/2022 at 11:35 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited
CCR
80075(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: The Licensee did not ensure C1 recieved the proper medication, which poses an immediate health, safety, and personal rights risk to clients in care.
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Plan of Correction POC Licensee agrees to administer medication training to staff by POC due date.

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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: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
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