<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203451
Report Date: 12/14/2021
Date Signed: 12/14/2021 04:43:59 PM

Document Has Been Signed on 12/14/2021 04:43 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:MEADOW RISE FACILITYFACILITY NUMBER:
157203451
ADMINISTRATOR:BERNALES, AMABELLEFACILITY TYPE:
735
ADDRESS:624 MEADOW RISE COURTTELEPHONE:
(661) 399-2655
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 5CENSUS: 5DATE:
12/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator, Amabelle BernalesTIME COMPLETED:
12:21 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/13/2021, Licensing Program Analysts (LPAs) Walton and Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. Facility has one central entry and exit point. LPAs introduced selves, stated the purpose of the visit and was granted entry to the facility by Caregiver. LPAs met with Administrator, Amabelle Bernales.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPAs observed signs promoting social distancing and cough/sneeze etiquette. Facility staff observed without facial coverings. LPAs toured the facility kitchen. LPAs observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPAs observed a 30 day supply of PPE and cleaning supplies. LPAs checked residents' medication and observed a 30 day supply.

There are 3 private rooms and 1 shared bedroom. Beds in the shared bedroom observed to be at least 6 feet apart. LPAs observed the window in bedroom 1 to be broken. Liquid soap and paper towels are available in the bathrooms. Hand-washing signs were not observed in resident bathrooms. LPAs observed black mold growing on the shower curtain in bathroom 1. Per Administrator and Facility staff, the facility is cleaned twice a week.

Resident and staff temperature checks are documented daily. LPAs reviewed resident records and observed that 5 out of 5 residents do not have updated emergency contact information. Staff records were reviewed for good health.

Continued to LIC809-C
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/14/2021 04:43 PM - It Cannot Be Edited


Created By: Alexandria Walton On 12/14/2021 at 12:29 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: MEADOW RISE FACILITY
FACILITY NUMBER: 157203451

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA osberved a broken window in bedroom 1 and black mold on the shower curtain in bathroom 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2022
Plan of Correction
1
2
3
4
Licensee agreed to replace the window and shower curtain and submit documentation showing that the corrections were made by the POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: MEADOW RISE FACILITY
FACILITY NUMBER: 157203451
VISIT DATE: 12/14/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs are requesting the following documents be submitted to the Fresno CCL office by 12/28/2021: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Based on today's inspection, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, see attached 809D



Exit interview conducted, and a plan of correction was reviewed and developed with Administrator. As a COVID-19 precautionary measure, a copy of this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document. Report signed on-site.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3