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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202907
Report Date: 09/19/2022
Date Signed: 09/23/2022 08:06:08 AM

Document Has Been Signed on 09/23/2022 08:06 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:HALF MOON HOMEFACILITY NUMBER:
157202907
ADMINISTRATOR:GLENN, RHONDAFACILITY TYPE:
735
ADDRESS:3509 SOUTH HALF MOON DRIVETELEPHONE:
(661) 833-6333
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 6CENSUS: 5DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Cheryl McCraw, Co-AdministratorTIME COMPLETED:
11:50 AM
NARRATIVE
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On 9/19/22 at 9:50 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.

LPA toured inside and outside of facility. Facility was observed clean and without any obstructions or fire clearance issues. 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 sinks. Residents each have a private room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Bulk of PPE supplies are kept at the facility’s main office. Residents files have updated emergency contact information. Administrator certification is current.

The following deficiency was observed:
1. In bedroom #2, the floor plank ends are detached in 12 areas of the bedroom floor; and the pull chain of the exterior exit gate was observed missing.

The following forms are to be submitted to CCL within 2 weeks:
LIC610D, LIC500, LIC402

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Co-Administrator. A copy of this report and appeal rights were given to Co-Administrator Cheryl McCraw, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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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Document Has Been Signed on 09/23/2022 08:06 AM - It Cannot Be Edited


Created By: Malia Thao On 09/19/2022 at 11:07 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: HALF MOON HOME
FACILITY NUMBER: 157202907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022

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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Based on observation, the licensee did not comply with the section cited above. In bedroom #2, the floor plank ends were detached in 12 areas of the bedroom floor; and the pull chain of the exterior exit gate was observed missing, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
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Licensee will submit proof of new flooring installed in bedroom #2 and a new pull chain installed on the exterior exit gate 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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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: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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