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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203990
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:40:55 AM

Document Has Been Signed on 08/13/2024 11:40 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:ALLISON MORGAN RESIDENCEFACILITY NUMBER:
157203990
ADMINISTRATOR/
DIRECTOR:		ALLISON, KEVINFACILITY TYPE:
735
ADDRESS:7308 STELLA COURTTELEPHONE:
(661) 679-4946
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 3CENSUS: 3DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:29 AM
MET WITH:Juanita Keeton, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 8/13/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit and allowed entrance by caregiver. Licensee/Administrator, Kevin Allison contacted by telephone and arrived a short time later to conduct facility inspection with LPA.

Currently there are three (3) residents in placement. Two residents were present at time of inspection, residents observed to be seating at dining room table preparing for breakfast at time of arrival.

Facility tour conducted. Facility observed to be well lit, and a comfortable temperature. Facility has 3 private bedrooms, resident bedrooms observed to have required furnishings. LPA observed R1 bedroom walls to have damage and in need of repair. LPA observed carpet throughout facility in need of cleaning. Air vent and filter in hallway is in need of cleaning and or replacement. Resident bathrooms toured, fixtures observed to be operational during inspection, water temperature measured at 112 degrees F. Both living room and dining room observed to have adequate seating for residents. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents. All knives are locked and secured in kitchen drawer. LPA observed kitchen island to have broken and missing tiles. Medications observed to be locked and secured in kitchen cabinet. LPA observed medications to have original labels, and to be administered as prescribed.

All cleaning supplies observed to be locked and secured under kitchen sink. Fire extinguisher present with a purchase date of 5/22/2024. Smoke detectors and carbon monoxide detectors present and observed operational on date of inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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 08/13/2024 11:40 AM - It Cannot Be Edited


Created By: Melinda Medina On 08/13/2024 at 10:41 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: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
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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: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
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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: ALLISON MORGAN RESIDENCE
FACILITY NUMBER: 157203990
VISIT DATE: 08/13/2024
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Outside of facility toured. All exits open free of obstruction. Pool is surrounded by a fence which is locked and inaccessible to residents. No hazards observed.

Based on today’s inspection and per California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached 809D.

Staff and resident files reviewed.

Exit interview conducted. Appeal rights provided and a copy of this report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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