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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202539
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:06:43 AM

Document Has Been Signed on 12/20/2024 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:POSITIVE PURPOSE, LLCFACILITY NUMBER:
157202539
ADMINISTRATOR/
DIRECTOR:		NIKKI COCKRENFACILITY TYPE:
735
ADDRESS:9008 STATEN ISLAND DRIVETELEPHONE:
(661) 847-9200
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Nikki CockrenTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On 12/20/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met with staff Amber Zargoza. Administrator Nikki Cockren was called and arrived shortly. Two clients were present during upon LPA arrival and left the facility during inspection. LPA toured facility with Administrator.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Fire extinguisher was observed with a service date: 10/06/23. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 34 degrees F and freezer at 0 degrees F. Cleaning supplies and chemicals stored and locked in chemical closet. Extra linens were observed. Washer and dryer observed operational during visit.All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Hot water temperature was tested at 114.2 degree F in room A bathroom, 118.2 degree F in room B bathroom, and 114.1 degree F in hall bathroom.

Outside of facility toured and observed to be free of debris. Adequate outdoor seatings available for clients. Side gate observed self-latching and self-closing. Smoke detectors and carbon monoxide were observed operational during visit. All clients’ and sample of clients’ and staff files were reviewed to have all required documents. First Aid kit observed with all required items. Medications were observed locked facility office drawer. MARS were reviewed and medications were checked.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. Exit Interview conducted. LPA received copies of Lic 308, Lic 500, Lic 610D, Lic 9020, and current Administrator certificate. A copy of this report and appeal rights was provided to Administrator, whose signature confirms received of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 11:06 AM - It Cannot Be Edited


Created By: Mai Yang On 12/20/2024 at 10:39 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: POSITIVE PURPOSE, LLC
FACILITY NUMBER: 157202539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80064(a)(3)
80064 (a)(3) Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3)Knowledge of and ability to comply with applicable law and regulation.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a purchased date of 10/06/2024, which poses an immediate health and safety risk to the clients.
POC Due Date: 12/21/2024
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 12/21/24.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/20/2024 11:06 AM - It Cannot Be Edited


Created By: Mai Yang On 12/20/2024 at 10:39 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: POSITIVE PURPOSE, LLC
FACILITY NUMBER: 157202539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
80075(b)(5)(C) A record of each dose is maintained in the resident's record. The record shall include the date and time medication was taken, the dosage taken, and the resident's response.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, R1’s medications were all checked and accounted for, in the
MARs was not documented to reflect the medication given, which poses/posed a potential health and safety risk to the person in care.
POC Due Date: 12/26/2024
Plan of Correction
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Administrator agree to submit a written statement detailing the steps the facility will take to ensure that the MARs are documented correctly. Written statement will be submitted to the department by POC due date 12/26/24.
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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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