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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202487
Report Date: 08/22/2022
Date Signed: 08/22/2022 12:50:16 PM

Document Has Been Signed on 08/22/2022 12:50 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:MISSION WELLS, INC. SADDLEBACKFACILITY NUMBER:
157202487
ADMINISTRATOR:RAMIREZ, CLAUDIAFACILITY TYPE:
735
ADDRESS:7008 SADDLEBACK DR.TELEPHONE:
(661) 832-3400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Helen Houck, LicenseeTIME COMPLETED:
01:15 PM
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On 8/22/2022 at 11:50 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator Helen Houck arrived a short time later.

LPA conducted tour with staff and did not observe any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Administrator certificate is valid.

The following deficiency was observed:
1. Bottom panel of sliding door in living room observed broken with sharp edges and screen door mesh observed with three holes torn approximately 1.5 inches by 1.5 inches

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.


The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D (new revision)

Exit interview conducted. A copy of this report and a Plan of Correction was reviewed and developed with Licensee Helen Houck, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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 08/22/2022 12:50 PM - It Cannot Be Edited


Created By: Malia Thao On 08/22/2022 at 12:32 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: MISSION WELLS, INC. SADDLEBACK
FACILITY NUMBER: 157202487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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. Bottom panel of sliding door in living room observed broken with sharp edges and screen door mesh observed with three holes torn approximately 1.5 inches by 1.5 inches, which pose a potential safety or personal rights risk to persons in care.
POC Due Date: 09/19/2022
Plan of Correction
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Licensee will submit proof of bottom panel of sliding door in living room replaced and screen door mesh replaced to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
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