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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204005
Report Date: 10/16/2024
Date Signed: 10/18/2024 01:01:01 PM

Document Has Been Signed on 10/18/2024 01:01 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:SIERRA SPRINGS RESIDENTIAL CAREFACILITY NUMBER:
157204005
ADMINISTRATOR/
DIRECTOR:		NANKIL, PATRICKFACILITY TYPE:
735
ADDRESS:305 DANI ROSE LANETELEPHONE:
(661) 399-4787
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93308
CAPACITY: 4CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Patrick Nankil, Licensee/Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 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 10/16/24, Licensing Program Analysts (LPA) L. Salazar and M. Medina arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Staff S1, stated the purpose of the visit and was allowed entry into the facility. LPA Salazar will conduct the physical plant portion of the inspection. LPA Medina will conduct the records review portion of the inspection and document on a separate report. Administrator on record is Patrick Nankil, Certificate# 7003773735 , Exp. 03/18/24.

LPA conducted a tour of the facility inside and out with Administrator. LPAs observed 1 resident in care at the time of visit. Facility is a 5 bedroom 3 bathroom home. Residents bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Facility temperature was 74 degrees F. Night lights were observed in the hallways. Window blinds, baseboards and walls throughout the house are observed with dust/dirt and/or partially painted. Padlock hasp / door latch (without a lock) was observed on a kitchen cabinet, hallway closet and laundry room exit door and are being removed.

Medications were observed to be locked in a cabinet located in the kitchen. The baseboard in the nook of the kitchen is dirty and separating from the wall. Cleaning supplies were observed to be locked under the kitchen sink. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables. Bags of rice were observed open and improperly stored There is 1 out of 4 residents with a modified diet. There are no resident's with restricted health conditions.

Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 109 degrees F. Trash cans with lids and hand washing postings were not observed in the bathrooms. Personal shower scrubs were observed hanging from the toilet paper holder next to the toilet.

Carbon monoxide and smoke detectors were tested and observed to be operational. Fire Extinguisher was observed with a service date of 10/06/24. First aid kit was observed and contained all required items. Internet and a working phone line was observed to be available for residents in care, however, there is no device for telecommunications.

Quarterly Emergency Disaster Drill logs were observed for staff to have occurred in June 2024. LPA observed on the LIC 610D (Emergency Disaster Plan) with emergency numbers and evacuations locations was posted in the kitchen. A sample of P&I of records was reviewed by Service Coordinator from Kern Regional observed to not balance and no receipts were observed for purchases.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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
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: 10/16/2024
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
(Continued from 809)

The exterior tour of back yard was conducted. The fence on the east side of the house was observed to be leaning and help up with boards. A covered outdoor seating area was observed. West side self-latching gate hardware was missing and screws were observed loose on the brackets holding the gate. The stucco on the west side of the house was observed to be muddy from a newly created cement. LPA observed stucco on the south side of the house to be peeling. 4 out of 5 window screens are bent and do not fit properly in the window.

Miscellaneous items were observed being stored on the patio that include a screen door, ladder, mop, a bucket of water with clothes in it, night stand, lamp and miscellaneous chairs/stools. A small wasp nest and cobwebs were observed on the patio. A yellow clothesline was observed to cross a portion of the patio. An old metal gate and bike were observed stored by the fence next to the gazebo.

Based on today's observations and per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809-D. If not corrected, this poses a potential risk to the heath, safety and or personal rights of residents in care. An exit interview was conducted with Administrator with a plan of correction due date of 11/01/24. A copy of this report and appeal rights were discussed and provided via email with a read receipt as proof of delivery.

To improve the quality and value of the inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. Note: The intent of the Facility Licensee Feedback Survey is to provide CDSS with information regarding the CARE Tools and inspection process.

If you have any questions regarding the inspection, please reach out to me or anyone at your RO. Website “For additional information regarding the inspection and its CARE Tools and methods, please visit the CARE Tools web page or the Inspection Process Project web page.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/18/2024 01:01 PM - It Cannot Be Edited


Created By: Lisa Salazar On 10/16/2024 at 01:17 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: SIERRA SPRINGS RESIDENTIAL CARE
FACILITY NUMBER: 157204005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

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
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above in 11 out of 12 rooms/areas in the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
.Licensee will have house cleaned, repaired and painted in all areas identified during the facility tour. Licensee will have a quote and the anticipated completion date to replacement the outside fence on the East side of the house by POC date.
Type B
Section Cited
HSC
1537.1(a)
Regulations
(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with licenee and resident, the licensee did not comply with the section cited above in 1 out of 1 internet access devices that is equipped with the above requirements, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
1
2
3
4
Licensee will provide a device for residents in care by POC date.
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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3