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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204078
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:42:18 PM

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:CELINE'S VILLAFACILITY NUMBER:
157204078
ADMINISTRATOR:SILVA, WENDYFACILITY TYPE:
735
ADDRESS:3621 KAPRAL WAYTELEPHONE:
(661) 564-8889
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Wendy Silva, LicenseeTIME COMPLETED:
11:10 AM
NARRATIVE
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On 1/27/22 at 8:31 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Licensee Wendy Silva arrived a short time later.

LPA toured facility with staff. LPA did not observe any obstructions or fire clearance issues. LPA observed COVID-19 precaution signs posted and sign-in table at entrance. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed next to the sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. Administrator certification is valid.

The following deficiencies were observed:
1. Hot water in hall bathroom measured at 121.1 degrees F.
2. Both freezer and refrigerator doors on kitchen refrigerator were observed with locks installed and actively locked during inspection.
3. Facility did not have 7-day supply of non-perishable foods.

The following update forms to be sent to CCL within 2 weeks:
LIC500, LIC610D, LIC400, LIC402, LIC308

Deficiencies are being cited based on LPA's observations and interview in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. Due to COVID-19 precautionary measures, a copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report. LPA verified email on record is correct with Licensee Wendy Silva.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
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 6
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: CELINE'S VILLA
FACILITY NUMBER: 157204078
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (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:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. Hot water in hall bathroom measured at 121.1 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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Licensee will submit proof of hot water in hall bathroom measuring within regulation of 105 through 120 degrees F to CCL by POC due date.
Type A
Section Cited
CCR
80072(a)(3)

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:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPA observed refrigerator in kitchen had locks installed on both freezer and refrigerator doors that were actively locked during inspection, which poses an immediate health or personal rights risk to persons in care.
POC Due Date: 01/28/2022
Plan of Correction
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Licensee will submit proof that both locks installed on freezer and refrigerator doors of refrigerator in kitchen are removed to CCL by POC due 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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: CELINE'S VILLA
FACILITY NUMBER: 157204078
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interview, the licensee did not comply with the section cited above. Facility did not have 7-day supply of non-perishable food, which poses a potential health or personal rights risk to persons in care.
POC Due Date: 01/31/2022
Plan of Correction
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Licensee will submit proof of receipt for purchase of non-perishable food and proof of purchased non-perishable foods to CCL by POC due date.
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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6