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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204205
Report Date: 01/27/2022
Date Signed: 01/27/2022 06:05:20 PM

Document Has Been Signed on 01/27/2022 06:05 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:EDGEMONT HOMEFACILITY NUMBER:
157204205
ADMINISTRATOR:MCCRAW, CHERYLFACILITY TYPE:
735
ADDRESS:5501 EDGEMONT DRIVETELEPHONE:
(661) 833-8805
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 3DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cheryl McCraw, AdministratorTIME COMPLETED:
01:45 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 1/27/22 at 11:30 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Administrator Cheryl McCraw 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 deficiency was observed:
1. LPA observed base of hall bathroom vanity and cabinet under kitchen sink, and right panel of hall bathroom vanity were rotted; hall bathroom full bathtub rim where bathtub meets surround wall tile and side wall was observed open and exposed; bathtub trim lever faceplate observed covered in calcium; and kitchen sink faucet observed leaking water.

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

Deficiency is being cited based on LPA's observations 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 Administrator Cheryl McCraw.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
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 2
Document Has Been Signed on 01/27/2022 06:05 PM - It Cannot Be Edited


Created By: Malia Thao On 01/27/2022 at 12:59 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: EDGEMONT HOME
FACILITY NUMBER: 157204205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022

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 observations, the licensee did not comply with the section cited above. LPA observed base of hall bathroom vanity and cabinet under kitchen sink, and right panel of hall bathroom vanity were rotted; hall bathroom full bathtub rim where bathtub meets surround wall tile and side wall was observed open and exposed; bathtub trim lever faceplate observed covered in calcium; and kitchen sink faucet observed leaking water, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2022
Plan of Correction
1
2
3
4
Administrator will submit proof of replacement of the bases of hall bathroom vanity and kitchen cabinet under sink, replacement of right side panel of hall bathroom vanity and bathtub trim lever faceplate, re-caulking of hall bathroom full bathtub rim where bathtub meets the surround wall tile and side wall, and proof of receipt of purchase and installation of kitchen sink faucet to CCL by POC due date.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
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: 2 of 2