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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204138
Report Date: 06/17/2024
Date Signed: 06/18/2024 05:17:16 PM

Document Has Been Signed on 06/18/2024 05:17 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:MISSION WELLS, INC.-HESKETHFACILITY NUMBER:
157204138
ADMINISTRATOR/
DIRECTOR:		HOUCK, HELENFACILITY TYPE:
735
ADDRESS:6205 HESKETH DRIVETELEPHONE:
(661) 324-3277
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:08 AM
MET WITH:Administrator, Helen HouckTIME VISIT/
INSPECTION COMPLETED:
02:34 PM
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On 06/17/2024 Licensing Program Analyst (LPA) M. Garza arrived unannounced for an annual inspection visit. LPA contacted Administrator, Helen Houck. Administrator arrived some time later. LPA was met with Administrative Assistant, Crystianna Robinson and House Manager, Naw Briana. LPA introduced self, explained reason for visit and was permitted entry into the facility.

3 of 4 residents at day program during time of inspection. 1 resident present with 1:1 staff during time of inspection. LPA toured the facility inside and out. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors present and operational on a system at time of visit. Fire extinguisher last serviced 05/14/24. Last fire drill on 04/10/24. Resident rooms observed to have the required furnishings and with adequate lighting. Sharps and medications were located in locked cabinets/drawers. LPA observed sufficient seating under covered patio areas. Sample resident/staff files reviewed and obtained the required documentation.

The following issues were observed at the facility: 2 of 2 resident restrooms and 3 of 3 resident rooms observed with chemicals (hygiene products)/items that could pose a danger to residents in care unlocked and accessible. Spider webs observed on back side fence. Facility has current pest control and will contact for service. Water temperature measured at 103.8. Facility has current water log showing water measures at required temperatures. Facility was doing laundry during time of visit. Deficiency/TV's provided for these issues.

LPA requested the following documents to be submitted to CCL by 06/24/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file.

Exit interview completed with Administrator, Helen Houck. A copy of this report, deficiency, TA's and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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 06/18/2024 05:17 PM - It Cannot Be Edited


Created By: Mary Garza On 06/17/2024 at 02:03 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: MISSION WELLS, INC.-HESKETH
FACILITY NUMBER: 157204138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building 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 LPA observation, the licensee did not comply with the section cited above in that 2 of 2 residents restrooms and 3 of 3 residents rooms observed with chemicals unlocked and accessible to residents in care. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Facility immediately locked chemicals/items that could pose a danger. Licensee to talk to KRC regarding modifications to IPP's. Email to CCL by POC 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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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