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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202532
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:49:17 PM

Document Has Been Signed on 08/19/2021 04:49 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:KERN TRANSITION HOME-RIVER GLENFACILITY NUMBER:
157202532
ADMINISTRATOR:GONZALEZ, TIFFANYFACILITY TYPE:
735
ADDRESS:4409 RIVER GLEN DRIVETELEPHONE:
(661) 213-3800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Program Director, Lauren HornTIME COMPLETED:
01:00 PM
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On 08/19/2021, Licensing Program Analysts (LPAs) Walton and Yang arrived unannounced to conduct a Case Management Inspection. LPAs introduced selves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Program Director, Lauren Horn.

It was reported that on 05/16/2021, S1 transported R1 for a community outing. While the vehicle was stopped, R1 unbuckled the seat belt and exited the vehicle. R1 "ran across the street" and was struck by Public Transportation. Facility staff initiated emergency services, paramedics arrived and transported R1 to the hospital.

Based on today's visit, a deficiency is being cited in the area evaluated and listed on the 809D according to California Code of Regulations, Title 22, Division 6. An immediate civil penalty in the amount of $500 is being assessed in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted. A plan of correction has been developed and reviewed. As a COVID-19 precautionary measure, a copy of this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 08/19/2021 04:49 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/19/2021 at 12:30 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: KERN TRANSITION HOME-RIVER GLEN
FACILITY NUMBER: 157202532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited
CCR
80078(a)

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85065 Personnel Requirements (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. THis requirement was not met as evidenced by:
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Licensee will submit a plan detailing steps the faciltiy will take to ensure the facility has staff necessary to provide care and supervision to residents in care by 08/20/2021.
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Based on interviews and record reviews, the facility did not ensure a sufficient numbner of staff to provide care and supervision to residents when R1 exited a vehicle and struck by public transportation during a community outing. This poses an immediate health and safety risk to persons in care.
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Licensee stated staff will receive training on the requriements of personnel requirements. Documentation of training topics and attandance will be submited to the Fresno CCL office by 9/20/2021.

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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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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