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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157203993
Report Date: 08/04/2022
Date Signed: 08/04/2022 09:48:22 AM

Document Has Been Signed on 08/04/2022 09:48 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:ROSAMOND RESIDENTIAL HOME AT SCHERER DRIVEFACILITY NUMBER:
157203993
ADMINISTRATOR:HARDGE, A. TERRENCEFACILITY TYPE:
735
ADDRESS:3833 SCHERER DRIVETELEPHONE:
(661) 256-4413
CITY:ROSAMONDSTATE: CAZIP CODE:
93560
CAPACITY: 6CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Administrator Terrance Hardge via telephone and caregiver Yolanda De Avila TIME COMPLETED:
10:00 AM
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On 8/4/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Yolanda De Avila, caregiver. Administrator Terrance Hardge was called and unable to attend meeting. Administrator authorized caregiver to received and sign report. LPA conducted a facility tour with caregiver. There are currently one client present during tour.

Upon entry facility staff was observed with facial mask. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. LPA checked clients’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 7/24/22.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed four bedrooms that are single occupant and two vacant bedrooms. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in facility office.

The exterior tour was conducted. Outside observed free of obstruction. At 08:43 a.m., LPA and caregiver observed gardening tools and paint cans stored in garage unlock. Staff’s record was reviewed for good health. All clients’ records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 8/10/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 808, Lic 610D and Lic 9282. A copy of this report and appeal rights was provided to the caregiver and Administrator via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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 08/04/2022 09:48 AM - It Cannot Be Edited


Created By: Mai Yang On 08/04/2022 at 09:22 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: ROSAMOND RESIDENTIAL HOME AT SCHERER DRIVE
FACILITY NUMBER: 157203993

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at 08:43 a.m. Licensing program analyst (LPA) and staff 1 (S1) observed on the left side of the garage multiple pain cans and gardening tool hanging on garage wall. Gardening tool observed described as a shovel, string trimmer, and looper. Gardening tools and paint cans observed to be stored in garage unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2022
Plan of Correction
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Staff removed gardening tools and paint cans into locked office. POC clear during visit.
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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022


LIC809 (FAS) - (06/04)
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