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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202519
Report Date: 01/10/2022
Date Signed: 01/10/2022 05:59:11 PM

Document Has Been Signed on 01/10/2022 05:59 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:CRESTMONT LOFTFACILITY NUMBER:
157202519
ADMINISTRATOR:CHRISTIE O'NEALFACILITY TYPE:
735
ADDRESS:1714 CRESTMONT DRTELEPHONE:
(661) 742-1383
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 4CENSUS: 4DATE:
01/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Christie O'Neal, Administrator
Samira Hernandez, House Manager		TIME COMPLETED:
12:15 PM
NARRATIVE
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On 1/10/22 at 9:10 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. House Manager (HM) Samira Hernandez and Administrator (ADM) Christie O'Neal arrived a short time later.

LPA toured facility inside and outside of facility with staff. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed next to the sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.

The following deficiencies observed:
1. Hot water in south hall bathroom measured at 137.4 degrees F.
2. South hall bathroom shower light not operating and bathtub spout leaking water. Bedroom #4 bathroom sink faucet leaking water. Ramp outside laundry area in disrepair. LPA observed an approximately 12" x 18" size cut out in ramp with board inside cut out to cover opening inside ramp walkway. Fire exit gate not operating as self-closing, is hanging by top hinge, and has nails sticking out of door.

The following update forms to be sent to CCL within 2 weeks:
LIC500, LIC610D, LIC400, LIC402, LIC308

Deficiency is being cited based on LPAs' observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA verified email on record is correct with Administrator Christie O'Neal.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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 01/10/2022 05:59 PM - It Cannot Be Edited


Created By: Malia Thao On 01/10/2022 at 11:00 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: CRESTMONT LOFT
FACILITY NUMBER: 157202519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

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. Hot water in south hall bathroom measured at 137.4 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2022
Plan of Correction
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Administrator will submit proof of hot water in south hall bathroom measuring within range 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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4
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/10/2022 05:59 PM - It Cannot Be Edited


Created By: Malia Thao On 01/10/2022 at 11:00 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: CRESTMONT LOFT
FACILITY NUMBER: 157202519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022

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 observations and interviews, the licensee did not comply with the section cited above. South hall bathroom shower light not operating and bathtub spout leaking water. Bedroom #4 bathroom sink faucet leaking water. Ramp outside laundry area in disrepair. LPA observed an approximately 12" x 18" size cut out in ramp with board placed inside cut out to cover opening, inside ramp walkway. Fire exit gate not operating as self-closing, is hanging by top hinge, and has nails sticking out of door, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2022
Plan of Correction
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Administrator will submit proof of south hall bathroom shower light replaced and operating; south hall bathroom bathtub spout and bedroom #4 sink faucet repaired of leaking water; ramp outside laundry area will be repaired so cover for cut out is flushed with ramp and ramp is covered so cut out is not exposed; and fire exit gate will be repaired to be self-closing and nails nailed down or removed as needed 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022


LIC809 (FAS) - (06/04)
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