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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203255
Report Date: 08/29/2024
Date Signed: 08/30/2024 07:11:14 AM

Document Has Been Signed on 08/30/2024 07:11 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:MARIPOSA ARFFACILITY NUMBER:
157203255
ADMINISTRATOR/
DIRECTOR:		SEDAM, RUSSFACILITY TYPE:
735
ADDRESS:1106 MINTER AVENUETELEPHONE:
(661) 746-4864
CITY:SHAFTERSTATE: CAZIP CODE:
93263
CAPACITY: 4CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:54 PM
MET WITH:Russ SedamTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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On 8/29/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced case management visit. LPA arrived, introduced self, stated purpose of visit and allowed entrance by direct care staff. Administrator, Russ Sedam contacted by telephone and arrived a short time later to conduct visit with LPA.

LPA arrived to follow up on a self reported incident which was received by Department on 8/6/24 which involved resident 1 (R1). It was reported to department that R1 received medications for 8:00 PM at 8:00 AM and 8:00 PM at 8:00 AM.

LPA reviewed centrally stored medication for R1. Incident was immediately reported to primary care physician and facility advised R1 required no medical attention.

Staff 1 (S1) and Staff 2 (S2) as well as remaining staff have received additional medication training on 8/8/24, 8/9/24 and 8/16/24.

No deficiencies cited

Exit interview conducted and a copy of report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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