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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204220
Report Date: 02/17/2022
Date Signed: 02/17/2022 06:01:24 PM

Document Has Been Signed on 02/17/2022 06:01 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:CELINE'S VILLA 2FACILITY NUMBER:
157204220
ADMINISTRATOR:SILVA, WENDYFACILITY TYPE:
735
ADDRESS:6600 CASWELL AVENUETELEPHONE:
(661) 832-1170
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Wendy Silva, Licensee/AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 2/17/22 at 11:15 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee/Administrator Wendy Silva. There was one resident present during the inspection.

LPA toured inside and outside of the facility with Licensee. 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. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. There were no fire clearance issues. Administrator certification is valid.

The following deficiencies were observed:
1. S1 does not have a health screening. S1 started working in the facility on 2/16/16.
2. Hot water in hall bathroom measured 121.7 degrees F.
3. Both fire exit gates outside the facility were inaccessible from inside backyard. Licensee could not open the either gates from inside yard. Staff walked around to front yard to push exit gates open. Left exit gate latch was nonoperational and right exit gate had enterior latch in locked position and only accessible from exterior side of gate.
4. Dining room window screen frame observed bent on bottom end.

The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC610D (new revision), LIC400, LIC402, LIC308

Continue on LIC809-C.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 5
Document Has Been Signed on 02/17/2022 06:01 PM - It Cannot Be Edited


Created By: Malia Thao On 02/17/2022 at 12:34 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: CELINE'S VILLA 2
FACILITY NUMBER: 157204220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

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 observation, the licensee did not comply with the section cited above. Hot water in hall bathroom measured 121.7 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2022
Plan of Correction
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Licensee adjusted hot water and LPA remeasured hot water in hall bathroom at 114.6 degrees F. POC cleared.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Both fire exit gates outside the facility were inaccessible from inside backyard. Licensee could not open the either gates from inside yard. Staff walked around to front yard to push exit gates open. Left exit gate latch was nonoperational and right exit gate had exterior latch in locked position and only accessible from exterior side of gate, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee will submit proof of left side exit gate replaced and operational, 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 Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/17/2022 06:01 PM - It Cannot Be Edited


Created By: Malia Thao On 02/17/2022 at 12:34 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: CELINE'S VILLA 2
FACILITY NUMBER: 157204220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observationa, the licensee did not comply with the section cited above. Dining room window screen frame observed bent up approximately 3 inches on bottom end, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will submit proof of dining room window screen frame replaced to CCL by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
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: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. S1 does not have a health screening. S1 started working in the facility on 2/16/16, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee will submit proof of health screening completed for S1 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 Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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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 2
FACILITY NUMBER: 157204220
VISIT DATE: 02/17/2022
NARRATIVE
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Continue on LIC809.

Deficiencies are being cited based on LPAs' observations, interview, and records review 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.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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