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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202789
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:28:01 PM

Document Has Been Signed on 06/27/2023 02:28 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:SVS BAKERSFIELD ADULT DAY PROGRAMFACILITY NUMBER:
157202789
ADMINISTRATOR:MENDEZ, CINTHYA GONZALEZFACILITY TYPE:
775
ADDRESS:3601 UNION AVETELEPHONE:
(661) 323-0533
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93305
CAPACITY: 90CENSUS: 43DATE:
06/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Latisha Albritton, Regional Director (Acting Administrator)TIME COMPLETED:
02:45 PM
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On 6/27/23 at 11:11 AM, Licensing Program Analyst (LPA) Malia Thao conducted a case management - deficiencies inspection. LPA met with Regional Director (Acting Administrator) Latisha Albritton.

During the inspection for complaint #24-AS-20230303162603, LPA found the following deficiency:

1. Facility did not complete an Admission Agreement for R1 at time of admission to the facility. R1 began receiving services on 10/24/22.

A deficiency is being cited based on LPA's record review and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted and a Plan of Correction was reviewed and developed with Regional Director Latisha Albritton. A copy of this report and appeal rights were given to Regional Director, whose signature confirms receipt of this report.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2023
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 2
Document Has Been Signed on 06/27/2023 02:28 PM - It Cannot Be Edited


Created By: Malia Thao On 06/27/2023 at 01:22 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: SVS BAKERSFIELD ADULT DAY PROGRAM
FACILITY NUMBER: 157202789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2023
Section Cited
CCR
82068(a)

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82068 Admission Agreements (a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.
This requirement was not met as evidenced by:
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Administrator will submit proof of a written statement stating the internal intake CIS100 form will be completed for each new client to ensure all required records are obtained and maintained prior to receiving services, to CCL by POC due date.
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During the inspection for complaint #24-AS-20230303162603, LPA found that the facility did not complete an Admission Agreement for R1 at time of admission to the facility. R1 began receiving services on 10/24/22. This poses a potential health, safety, or personal rights risk to residents 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:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023


LIC809 (FAS) - (06/04)
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