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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202532
Report Date: 02/22/2024
Date Signed: 02/22/2024 06:40:21 PM

Document Has Been Signed on 02/22/2024 06:40 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:WILLIAMS, DONTEFACILITY TYPE:
735
ADDRESS:4409 RIVER GLEN DRIVETELEPHONE:
(661) 213-3800
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Program Director Brandy Frazier and Quality Assurance TJ SandhuTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was met by Program Director Brandy Frazier. Program Director Brandy Frazier contacted attempted to contact Administrator Donte Williams who was unavailable. Program Director Brandy Frazier contacted Quality Assurance TJ Sandhu who responded to assist with the visit.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 107.3 degrees F. Facility was set at 68 F. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 02/1/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm. Facility smoke alarm is hard wired with sprinkler system. Last fire drill conducted 12/11/2023. All cleaning supplies are locked and secured in garage.

Medication records were reviewed. MARS log showed missing medications. Facility did not have a current centrally stored log. Staff files did not have health screening. LPA was unable to review Administrator file or Administrator certificate due to the file not being in the facility.

Refer to 809D for deficiencies.

An exit interview was conducted with the Administrator and a copy of this report along with plan of correction and appeal rights was provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 02/22/2024 06:40 PM - It Cannot Be Edited


Created By: Shawna Doucette On 02/22/2024 at 02:45 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 by having empty signatures showing missing medications in the MARS log for the month of 1/24 and 2/24 for C1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to conduct medication and MARS training for all staff. Licensee agrees to submit copy agenda of training and signature of each staff trained by POC due date 3/29/24
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/22/2024 06:40 PM - It Cannot Be Edited


Created By: Shawna Doucette On 02/22/2024 at 03:10 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: 02/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
(k) The following requirements shall apply to medications which are centrally stored:

(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above by not having a centrally stored log for clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to submit centrally stored logs for all clients in care by POC due date 3/29/24
Type B
Section Cited
CCR
80066(c)
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having Administrator file and Administrator certificate available for licensing to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to submit a written plan on how facility will comply with this regulation in the future by POC due date 03/29/24.
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024


LIC809 (FAS) - (06/04)
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