<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202855
Report Date: 06/29/2022
Date Signed: 06/29/2022 11:18:15 AM


Document Has Been Signed on 06/29/2022 11:18 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MISSION SPRINGS, INC.- HESKETHFACILITY NUMBER:
157202855
ADMINISTRATOR:RAMIREZ, CLAUDIAFACILITY TYPE:
735
ADDRESS:5901 HESKETH DRIVETELEPHONE:
(661) 321-9119
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Helen Houck, Licensee
Francisca Amado, House Manager		TIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/29/22 at 9:10 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee Helen Houck and House Manager Francisca Amado arrived a short time later. COVID-19 precautions are in place.

LPA toured inside and outside of the facility, and did not observe any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information.

LPA observed the following deficiency:
1. Kitchen drawer where sharps are kept was observed unlocked and accessible.

The following updated forms to be sent to CCL within 2 weeks:
-LIC500, LIC400, LIC402, LIC610D (new revision)
-Change of Administrator documents

LPA explained the Infection Control Plan has not been received and will need to be submitted to CCL within one week.

Exit interview conducted. A copy of this report and appeal rights were given to Licensee Helen Houck, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 06/29/2022 11:18 AM - 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: MISSION SPRINGS, INC.- HESKETH
FACILITY NUMBER: 157202855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee did not comply with the section cited above. LPA observed the kitchen drawer where sharps are kept was unlocked and accessible, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
1
2
3
4
Licensee immediately locked kitchen drawer. POC cleared during inspection
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2