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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203139
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:41:10 PM

Document Has Been Signed on 07/22/2024 12:41 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 TRANSITION HOME-MEADOW OAKSFACILITY NUMBER:
157203139
ADMINISTRATOR/
DIRECTOR:		MANIGQUE, LESTERFACILITY TYPE:
735
ADDRESS:5813 MEADOW OAKS COURTTELEPHONE:
(661) 871-7410
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 4CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Administrator Lester Manigque and Staff Melissa CarlileTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by Staff Melissa Carlile. Staff contacted Administrator Lester Manigque who responded to assist with the visit.

A tour of the facility was conducted with the Staff Melissa Carlile. The residence was set at 74 F temperature and free of passageway obstructions inside and outside.

LPA Doucette observed 4 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 110 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Knives were stored in a locked cabinet. Medications were stored in a locked Medication cart. Cleaning supplies were in a locked cabinet in the garage. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguishers were charged and had service dates of 2/01/24. Fire drill was last completed on 06/29/24. Facility has a pull station fire alarm. Facility has a sprinkler system.

LPA observed a self latching gate on the outside of the residence. There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. Facility had a medication errors this month on C1 on 4/13/24 rispiridone and C3 7/09/24 and 07/10/24 and 07/11/24 famotidine 20 mg was missed. Current first aid and CPR were on file for staff.

An exit interview was conducted with the Administrator. A copy of this report, appeal rights and plan of correction were discussed and left with the Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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 07/22/2024 12:41 PM - It Cannot Be Edited


Created By: Shawna Doucette On 07/22/2024 at 12:19 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: KERN TRANSITION HOME-MEADOW OAKS
FACILITY NUMBER: 157203139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in C2 missing a medication on 4/13/24 and C3 missing a medication on 07/09/24, 07/10/24 and 07/11/24 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee agrees to conduct a medication training by POC due date 07/22/24. Facility already completed medication training. Cleared during visit.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/22/2024 12:41 PM - It Cannot Be Edited


Created By: Shawna Doucette On 07/22/2024 at 12:19 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: KERN TRANSITION HOME-MEADOW OAKS
FACILITY NUMBER: 157203139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have a physicians report for C2, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to submit a completed physicians report for C2 by POC due date 08/16/24.
Type B
Section Cited
CCR
80075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have a completed centrally stored log for all four clients] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee agrees to submit copies of all four clients completed centrally stored logs by POC due date 07/26/24.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
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