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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157201395
Report Date: 01/06/2025
Date Signed: 01/06/2025 02:44:48 PM

Document Has Been Signed on 01/06/2025 02:44 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:CNS ALTA PEAKFACILITY NUMBER:
157201395
ADMINISTRATOR/
DIRECTOR:		GRIGSBY, DIEDRAFACILITY TYPE:
735
ADDRESS:7510 ALTA PEAKTELEPHONE:
(661) 665-9980
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 5CENSUS: 3DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Administrator Nora Rodriguez LopezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA met with Administrator Nora Rodriguez Lopez and was granted entry into the facility by staff.

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 an adequate supply of linen. Hot water measured at 1230.3 degrees F. Facility was set at 73 F.

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

Fire extinguisher serviced on 10/14/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Medications were stored at another location off site.

Staff files and resident files were reviewed. Medications were reviewed. R1's medication started on 8/19/24 and was directed to be administered once daily containing 200 pills. After conducting a pill count, R1 has 98 pills left and should have 61 pills left.

Facility does not have plan of operation at the facility. Administrator will submit plan of operation by tomorrow for LPA to review.

An exit interview was conducted with the Administrator and a copy of this report, plan of corrections and appeal rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 01/06/2025 02:44 PM - It Cannot Be Edited


Created By: Shawna Doucette On 01/06/2025 at 12:33 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: CNS ALTA PEAK
FACILITY NUMBER: 157201395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 waterd temperature measuring at 130.3 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Licensee agrees to submit a photo of corrected water temperature measuring in between 105 and 120 F by POC due date 1/7/24.
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in after condcuting a pill count, R1 had 98 pills and should have 61 pills left out of 200 with a start date showing 8/19/24, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Licensee agrees to provide a date to conduct a medication training and submit a plan of how medication will be administered correctly by POC due date 01/7/24.
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: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/06/2025 02:44 PM - It Cannot Be Edited


Created By: Shawna Doucette On 01/06/2025 at 12:33 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: CNS ALTA PEAK
FACILITY NUMBER: 157201395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee had admissions agreements for 3 residents from the previous facility and no admission agreement for current facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Licensee agrees to submit current admissions agreement for 3 residents by POC due date 1/10/24.
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: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
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