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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202862
Report Date: 02/28/2022
Date Signed: 02/28/2022 05:28:14 PM

Document Has Been Signed on 02/28/2022 05:28 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KERN RESIDENTIAL SERVICES, INC. (LAYTON HOME)FACILITY NUMBER:
157202862
ADMINISTRATOR:GLENN, RHONDAFACILITY TYPE:
735
ADDRESS:2717 LAYTON DRIVETELEPHONE:
(661) 396-9544
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Cheryl McCraw, Co-AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 2/28/22 at 8:50 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. Co-Administrator (ADM) Cheryl McCraw arrived a short time later. All four residents were present during inspection.

LPA toured facility with staff and ADM. LPA did not observe any obstructions or fire clearance issues. LPA observed COVID-19 precaution signs posted and sign-in table at entrance. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed next to the sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. Administrator certification is valid.



The following deficiencies were observed:
1. Hot water in hall bathroom measured at 130.1 degrees F.
2. Bedroom #1 ceiling fan blades observed covered in dust. Bedroom #3 door observed with an 4" x 2" inch hole and right wall outside bedroom #3 door observed with a 2" x 1" hole.

The following update forms to be sent to CCL within 2 weeks:
LIC500, LIC610D, LIC400, LIC402

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA verified email on record is correct.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2022
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 3
Document Has Been Signed on 02/28/2022 05:28 PM - It Cannot Be Edited


Created By: Malia Thao On 02/28/2022 at 10:52 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: KERN RESIDENTIAL SERVICES, INC. (LAYTON HOME)
FACILITY NUMBER: 157202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. Hot water in hall bathroom measured at 130.1 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2022
Plan of Correction
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Administrator will submit proof of hot water in hall bathroom measuring within regulation range of 105-120 degrees F to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/28/2022 05:28 PM - It Cannot Be Edited


Created By: Malia Thao On 02/28/2022 at 10:52 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: KERN RESIDENTIAL SERVICES, INC. (LAYTON HOME)
FACILITY NUMBER: 157202862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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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4
Based on observations, the licensee did not comply with the section cited above. Bedroom #1 ceiling fan blades observed covered in dust, bedroom #3 door observed with an 4" x 2" inch hole and right wall outside bedroom #3 door observed with a 2" x 1" hole, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2022
Plan of Correction
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Administrator will submit proof of bedroom #1 ceiling fan blades cleaned, and bedroom #3 door and right wall holes will be patched, to CCL by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022


LIC809 (FAS) - (06/04)
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