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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202782
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:50:13 PM


Document Has Been Signed on 03/22/2022 03:50 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:CHESHIREFACILITY NUMBER:
157202782
ADMINISTRATOR:SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:2417 CHESHIRE DRIVETELEPHONE:
(661) 836-1886
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 2DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Lead Staff, Lito PimentelTIME COMPLETED:
12:12 PM
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On 03/22/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Infection Control Inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. House Manager, Gonzalo Cruz (HM) is unable to attend this visit due to a prior engagement. LPA spoke with (HM) via telephone and received verbal permission to meet with Lead Staff, Lito Pimentel (LS).

There are 2 out of 2 residents present during today's visit.

LPA conducted a facility tour with LS. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lid. Hand washing posters were observed by the bathroom sink. The window screen in the bathroom window was missing. LPA observed a large hole in the bottom right corner of the bathroom door. Bedrooms are single occupant.

LPAs checked residents’ locked medications and observed a 30-day supply. Kitchen toured. A drawer is missing from the cabinet in the kitchen, Food supply was checked and there appeared to be an adequate supply. LPA observed food to be improperly stored which was evidenced by an open package of sausage that was freezer burned and multiple tomatoes in the refrigerator that were bruised and had a small amount of mold growing on top. The window in the dining area is missing, the facility placed a large piece of cardboard to cover the area.

Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Residents wear masks when away from the community.
CONTINUED TO 809C
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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: CHESHIRE
FACILITY NUMBER: 157202782
VISIT DATE: 03/22/2022
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An Annual Continuation Inspection will be conducted at a later date to review resident and staff records.

Based on today's inspection, deficiencies are being cited in accordance with the California Code of Regulations, Title 22, see attached LIC809D.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/05/2022: 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 (LIC610D) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020).

An exit interview was conducted, and a Plan of Correction was reviewed and developed. A copy of this report and appeal rights was discussed and will be provided via email due to COVID-19. Report signed on site by Facility Representative.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/22/2022 03:50 PM - It Cannot Be Edited

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: CHESHIRE
FACILITY NUMBER: 157202782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

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 as evidenced by the missing window, missing kitchen drawer, the hole in the bathroom door, and missing bathroom window screen, which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 04/22/2022
Plan of Correction
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Licensee agrees to repair or replace the window, missing drawer, bathroom door, and missing bathroom window screen and submit proof to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
80076(a)(18)
80076 Food Services: (a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately


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 as evidenced by the open package of sausage that was freezer burned and multiple bruised tomatoes with mold growth on top which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements of Section 80076(a)(18) are met to the Fresno CCL office by the POC due date.

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 HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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