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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202387
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:26:49 PM

Document Has Been Signed on 12/10/2021 01:26 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:MOUNTAIN VIEW RANCH RES. CAREFACILITY NUMBER:
157202387
ADMINISTRATOR:NANKIL, PATRICK R.FACILITY TYPE:
735
ADDRESS:3046 HINSLEY STTELEPHONE:
(661) 319-3749
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 4CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Rosalina and Tony Nankil, LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) L. Cabrera conducted an unannounced case management. LPA met with Licensee Rosalina and Tony Nankil.

During the investigation of a complaint, it was discovered that the facility failed to provide unusual incident reports regarding Client (C1) having bruises to Community Care Licensing and Responsible Party.

Deficiency cited on the attached LIC809-D. Exit interview conducted and Licensee was provided with a copy of this report and Appeal Rights.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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 2
Document Has Been Signed on 12/10/2021 01:26 PM - It Cannot Be Edited


Created By: Lady Cabrera On 12/10/2021 at 12:41 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: MOUNTAIN VIEW RANCH RES. CARE
FACILITY NUMBER: 157202387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
This requirement was not met as evidenced by:

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Licensee agreed to train staff on the requirements of 87211 Reporting Requirements. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 12/17/2021.
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Based on records review and interviews, facility failed to provide unusual incident reports regarding C1)having bruises to Community Care Licensing and Responsible Party, which poses a potential Health, Safety and Personal Rights risks to persons 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:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2021


LIC809 (FAS) - (06/04)
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