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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202532
Report Date: 01/31/2022
Date Signed: 01/31/2022 03:07:28 PM

Document Has Been Signed on 01/31/2022 03:07 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:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:04 AM
MET WITH:Administrator, Brandy Frazier and Program Supervisor, Antwanique WalkerTIME COMPLETED:
11:30 AM
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On 01/31/2022, Licensing Program Analyst (LPA) Walton conducted an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA met with Administrator, Brandy Frazier and Program Supervisor, Antwanique Walker. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility has no obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms do not have trash cans with lids. Hand washing posters were not observed by the bathroom sinks. LPA observed a tile in bathroom 1 to have a hole. The toilet in bathroom 1 had a constant running water noise. Bedrooms are single occupant. LPA observed the window screens to be missing in Room 1, Room 2, and the bathroom 1. LPA observed spider webs and dead insects on all window sills in client bedrooms. LPA observed 3 large holes in the wall of Room 3. LPA observed a broken chair with metal screws exposed in Room 3. Window blinds were broken and missing in Room 1, Room 2, and Room 4. LPA observed water on the toilet lid and floor of bathroom 2.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

Based on today's visit, a deficiency is being cited in the area evaluated and listed on the attached 809D according to California Code of Regulations, Title 22, Division 6.
CONTINUED TO LIC809C.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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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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: 01/31/2022
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LPA is requesting the following documents be submitted to the Fresno CCL office by 02/14/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with the Administrator and Program Supervisor. A plan of correction was reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this report and appeal rights will 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: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2022 03:07 PM - It Cannot Be Edited


Created By: Alexandria Walton On 01/31/2022 at 10:34 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: KERN TRANSITION HOME-RIVER GLEN
FACILITY NUMBER: 157202532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings 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 when the facility was found to be in good repair for 4 out 4 residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2022
Plan of Correction
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Licensee agrees to make repairs and submit proof to the Fresno CCL office by the 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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
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