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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203990
Report Date: 08/01/2022
Date Signed: 08/01/2022 12:06:14 PM

Document Has Been Signed on 08/01/2022 12:06 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:ALLISON MORGAN RESIDENCEFACILITY NUMBER:
157203990
ADMINISTRATOR:ALLISON, KEVINFACILITY TYPE:
735
ADDRESS:7308 STELLA COURTTELEPHONE:
(661) 679-4946
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 3CENSUS: 3DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Tori Morgan AllisonTIME COMPLETED:
12:24 PM
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On 8/01/2022, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Infection Control Inspection. LPA introduced self and allowed entrance by Direct Care Staff, Tori Morgan Allison. LPA was screened for COVID and observed visitor sign in available. Staff observed to be wearing masks. Kevin Allison serves as facility Administrator, Certificate #6011200735, expires 1/17/2024.

Tour of the facility conducted with Tori Morgan Allison. Adequate seating and lighting available in all common areas of the facility. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available. All medications is locked and secured in kitchen cabinet. Residents have a 30-day supply of medication available. Residents all have private bedrooms. Resident bathrooms toured, LPA observed paper towels and hand soap available. First Aid Kit available. Carbon monoxide and smoke detectors observed operational. Fire extinguisher is current. Water temperature measured at 140 degrees F.

Outside of facility toured, no obstructions observed. Pool is surrounded by a fence and is locked and secured.

Deficiencies cited on the attached 809D.

Exit interview conducted. Facility report signed during inspection and a copy provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2022
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 2
Document Has Been Signed on 08/01/2022 12:06 PM - It Cannot Be Edited


Created By: Melinda Medina On 08/01/2022 at 11:36 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: ALLISON MORGAN RESIDENCE
FACILITY NUMBER: 157203990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(1)
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by: LPA measured water temperature at 140 degrees F
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2022
Plan of Correction
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Licensee to adjust water heater and ensure that water temperature is within regulation.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022


LIC809 (FAS) - (06/04)
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