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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204005
Report Date: 10/20/2021
Date Signed: 10/20/2021 11:59:22 AM

Document Has Been Signed on 10/20/2021 11:59 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:SIERRA SPRINGS RESIDENTIAL CAREFACILITY NUMBER:
157204005
ADMINISTRATOR:NANKIL, PATRICKFACILITY TYPE:
735
ADDRESS:305 DANI ROSE LANETELEPHONE:
(661) 399-4787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:34 AM
MET WITH:Caregiver, Liza NacarioTIME COMPLETED:
12:00 PM
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On 10/20/2021, Licensing Program Analyst (LPA) 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 was granted entry to the facility by Caregiver, Liza Narcario. Caregiver contacted Administrator via telephone. Administrator was unable to attend this inspection. LPA received verbal permission to conduct the inspection with Caregiver, Liza Nacario.

Facility tour conducted with Caregiver. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette. LPA checked residents' medication and observed a 30 day supply. LPA toured the facility kitchen. LPA observed two refrigerators, the kitchen pantry, and all cabinets containing food to be locked. Per Caregiver, the facility did not have a waiver approving the locked refrigerators, pantry, and cabinets. Caregiver removed the locks, allowing food to be accessible. LPA observed a 7-day supply of perishable foods and a 2-day supply of perishable foods. LPA observed a 30 day supply of PPE and cleaning supplies.

Bedrooms are single occupant. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs observed in resident bathrooms. Resident temperature checks are documented daily. 3 out of 4 resident records have updated emergency contact information. Facility staff records reviewed for good health and infection control training.

Continued to LIC809C
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2021
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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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: SIERRA SPRINGS RESIDENTIAL CARE
FACILITY NUMBER: 157204005
VISIT DATE: 10/20/2021
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Based on today's inspection, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and a Plan of Correction was reviewed and developed. 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 by a facility representative.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2021 11:59 AM - It Cannot Be Edited


Created By: Alexandria Walton On 10/20/2021 at 11:40 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: SIERRA SPRINGS RESIDENTIAL CARE
FACILITY NUMBER: 157204005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
80072 Personal Rights
a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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 when all food in the facility was locked an inaccessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Licensee removed all the locks from the refrigerators, cabinets, and pantrys. POC CLEARED during inspection.
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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021


LIC809 (FAS) - (06/04)
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