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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204166
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:51:41 PM

Document Has Been Signed on 11/20/2024 05:51 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:SCOTT RESIDENTIAL, LLCFACILITY NUMBER:
157204166
ADMINISTRATOR/
DIRECTOR:		SCOTT, CYNTHIAFACILITY TYPE:
735
ADDRESS:1013 N. SIERRA VIEW STREETTELEPHONE:
(213) 590-9304
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 4CENSUS: 1DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:09 PM
MET WITH:Administrator Cynthia ScottTIME VISIT/
INSPECTION COMPLETED:
06:00 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
Licensing Program Analyst (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct a Required Annual inspection. LPA was met by Administrator Cynthia Scott.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, appeared clean and safe for food preparation. Food supply checked, LPA observed an adequate supply of food. Resident rooms checked. LPA observed an adequate supply of linen. Hot water measured at 112.6 degrees F. Facility was set at 79 F. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 11/06/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted 11/4/2024.

All cleaning supplies are locked and secured in a cabinet under the kitchen sink.

LPA reviewed resident and staff records. LPA reviewed medications.

Facility had uncleared family member residing in the facility. Refer to 809D. Civil Penalty was issued for Fingerprint clearance.

An exit interview was conducted with the Administrator and a copy of this report with plan of correction and appeal rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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 2
Document Has Been Signed on 11/20/2024 05:51 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/20/2024 at 05:26 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: SCOTT RESIDENTIAL, LLC
FACILITY NUMBER: 157204166

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(12)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee has a family member residing in the facility who was not fingerprint cleared, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
1
2
3
4
Licensee removed family member from the facility during visit. POC cleared during visit. Civil Penalty issued.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


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