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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202487
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:52:25 PM

Document Has Been Signed on 08/28/2024 01:52 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/
DIRECTOR:		RAMIREZ, CLAUDIAFACILITY TYPE:
735
ADDRESS:7008 SADDLEBACK DR.TELEPHONE:
(661) 832-3400
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 3DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Claudia RamirezTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Claudia Ramirez and House Manager Desiree Sales.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring 107 degrees in the resident bathroom. LPA observed hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals were locked are stored separate from food. Doors and passageways are unobstructed throughout the facility including outdoors. Medications are centrally stored and locked. A First aid kit contained required items. Facility has multiple visitation and common areas available. LPA walked the outdoor areas to find the grounds to be well kept with walkways and sitting areas. There is an inground pool surrounded by a gate which was locked. Fire extinguishers were serviced and charged on 5/14/24 by American Fire Safety Co. Combination smoke and carbon monoxide detectors were tested. LPA reviewed fire and Emergency Drill logs. LPA conducted resident and staff file reviews including a medication audit. Required postings were observed throughout the facility. Emergency Disaster and Infection Control Plans were reviewed during the inspection.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Functional Capabilities Assessment

See LIC809C for continuation of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/28/2024 01:52 PM - It Cannot Be Edited


Created By: Katie Brown On 08/28/2024 at 01:22 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: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA discovered that R1's Physician Report does not document ability to perform Glucose testing. R2's Physician Report is not complete.
POC Due Date: 09/30/2024
Plan of Correction
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AD agrees to obtain updated Physicians Reports (LIC602A) which are accurate and complete for R1 or R2. Copies of the updated Physician Reports will be submitted to CCLD by POC 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MISSION WELLS, INC. SADDLEBACK
FACILITY NUMBER: 157202487
VISIT DATE: 08/28/2024
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An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 9/28/24: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610D, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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