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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202532
Report Date: 02/22/2022
Date Signed: 02/22/2022 05:07:19 PM

Document Has Been Signed on 02/22/2022 05:07 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:
02/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Administrator, Brandy FrazierTIME COMPLETED:
10:20 AM
NARRATIVE
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On 02/22/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management Visit. LPA introduced self and was granted entry to the facility. LPA requested to speak with the Administrator. LPA met with Administrator, Brandy Frazier.

The purpose of today’s visit is to follow up on Incident Reports submitted to the Fresno CCL office. Due to COVID-19 precautionary measures, this visit was conducted outside of the facility with Administrator.

It was reported that on 4/15/2021, Facility staff were unable to locate the key for the medication cart. It was found that a staff member “accidentally took the keys home” which resulted in all residents missing morning medications.

It was reported that on 08/22/2021, R1 did not receive medications at the 12:00PM medication pass. Medications were left at the day program resulting in R1 missing the following medications: Perhenazine 40MG, Chlorpromazine 100MG, and Lorazepam 1MG.

It was reported that on 09/08/2021, R3 eloped from the facility at approximately 4:35AM while staff was attending to another resident in the facility. Facility staff searched the facility and was unable to locate R3. At approximately 5:13AM, facility staff was notified that R3 was “picked up” by the police. R3 was transported back to the facility at approximately 5:20AM by the Program Director.

It was reported on 10/17/2021, facility staff “forgot to give medications as prescribed” due to another incident that occurred at the facility on the same date. Residents did not receive morning medications.

CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: KERN TRANSITION HOME-RIVER GLEN
FACILITY NUMBER: 157202532
VISIT DATE: 02/22/2022
NARRATIVE
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It was reported that on 12/29/2021 at approximately 8:55AM, R3 eloped from the facility while staff was attending to another resident. Facility staff searched the facility and was unable to locate R3. Facility staff spoke with a store clerk at a nearby Fastrip. The store clerk informed staff that R2 was at the store, but, was transported to Kern Medical Center via Hall Ambulance. Facility staff contacted Kern Medical and located R3. R3 was cleared and released back to the facility.

Based on interviews and record review, deficiencies are being cited in accordance with California Code of Regulations, Title 22, see attached 809D. An immediate Civil Penalty is being assessed in the amount of $500 in accordance with California Code of Regulations, Title 22.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and Appeal Rights will be provided via email due to COVID-19 precautionary measures. Facility Representative signature on file.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
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Document Has Been Signed on 02/22/2022 05:07 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/22/2022 at 04:45 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: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2022
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure all clients are assisted with medications to the Fresno CCL office by 02/23/2022.
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Based on interviews and records reviews, the faciltiy did not ensure all clients were assisted with self-administrator of presecription medications on 04/15/2021, 08/22/2021, and 10/17/2021, which poses an immediate health and safety risk to persons in care.
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Type A
02/23/2022
Section Cited
CCR85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidienced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for Section 85078 are met to the Fresno CCL office by 02/23/2022.
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Based on interviews and records review, the licensee did not ensure R3 was supervised when R3 eloped from the facility on 09/09/2021 and 12/29/2021, which poses an immediate health and safety risk 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022


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