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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203276
Report Date: 01/27/2024
Date Signed: 01/28/2024 08:18:21 PM

Document Has Been Signed on 01/28/2024 08:18 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:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:House Lead Stephanie HernandezTIME 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 disclosed the purpose of the inspection and was granted entry into the facility by Staff Alyssa Merlo. LPA met with Administrator Melissa Galicia and House Manager Stephanie Hernandez, who responded to the facility to assist with the visit.

A tour of the facility was conducted with the House Manager Stephanie Hernandez. The residence was set at 76 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 117.5 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 in the office which is separate from the facility. Cleaning supplies were in a locked cabinet in kitchen. 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 7/6/23. Fire drill and earthquake drill were last completed on 1/23/24.

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. C1 did not have a physicians report in file. 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: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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 01/28/2024 08:18 PM - It Cannot Be Edited


Created By: Shawna Doucette On 01/27/2024 at 12:11 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: MCCLELLAN BOARD & CARE FACILITY #2
FACILITY NUMBER: 157203276

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2024

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 interview and record review, the licensee did not comply with the section cited above in C1 did not have a physician report in C1's file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
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Plan of Correction POC Licensee agrees to submit a current physician report LIC602 by POC due date 3/1/24.
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: 01/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024


LIC809 (FAS) - (06/04)
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