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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203276
Report Date: 03/30/2023
Date Signed: 03/30/2023 12:04:46 PM

Document Has Been Signed on 03/30/2023 12:04 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:MCCLELLAN BOARD & CARE FACILITY #2FACILITY NUMBER:
157203276
ADMINISTRATOR:GALICIA, RUDOLPHOFACILITY TYPE:
735
ADDRESS:825 FOXTREE COURTTELEPHONE:
(661) 366-7864
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 5CENSUS: 5DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Administrator Melissa GaliciaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Melissa Galicia. LPA disclosed the purpose of the inspection and was granted entry into the facility by Staff Stephanie Hernandez.

A tour of the facility was conducted with the Administrator. The residence was set at 68 F temperature and free of passageway obstructions inside and outside.

LPA Doucette observed 5 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 117 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 cabinet. Cleaning supplies were in a locked cabinet. First Aid Kit contained the required supplies. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm. Fire extinguishers were charged and had service dates of 5/2/22. Fire drill was last completed on 2/03/23.

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. LPA observed a medication error for C1. Current first aid and CPR were on file for staff.

Per Title 22, deficiency was issued. Refer to 809D.

An exit interview was conducted with Administrator Melissa Galicia. A copy of this report was left with Administrator Melissa Galicia, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 03/30/2023 12:04 PM - It Cannot Be Edited


Created By: Shawna Doucette On 03/30/2023 at 11:52 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: MCCLELLAN BOARD & CARE FACILITY #2
FACILITY NUMBER: 157203276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2023

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 obervation, record review, and staff interview, the licensee did not comply with the section cited above in 1 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee agrees to conduct medication training with all staff by 04/14/23. Licensee agrees to submit copy of training agenda and staff signatures of completed training.
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: 03/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023


LIC809 (FAS) - (06/04)
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