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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206256
Report Date: 05/05/2022
Date Signed: 05/06/2022 11:00:50 AM

Document Has Been Signed on 05/06/2022 11:00 AM - 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:LIBERTY IN THE WESTFACILITY NUMBER:
157206256
ADMINISTRATOR:ERIC CORONADOFACILITY TYPE:
735
ADDRESS:15913 SAN MARCO PLTELEPHONE:
(661) 332-2949
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 4CENSUS: 4DATE:
05/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator Eric Coronado and Supervisor Daniel EsparzaTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst LPA conducted a Case Management to follow up on an incident report that occurred on 12/4/21. LPA was met by Administrator Eric Coronado and discussed the purpose of the visit.

LPA reviewed records and interviewed Administrator and staff.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 809D. Civil Penalties were issued.

An exit interview was conducted with Administrator Eric Coronado and a copy of this report with Plans of Corrections and appeal rights was provided to Administrator Eric Coronado.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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 05/06/2022 11:00 AM - It Cannot Be Edited


Created By: Shawna Doucette On 05/05/2022 at 12:31 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: LIBERTY IN THE WEST
FACILITY NUMBER: 157206256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
85078(a)(1)

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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply: (1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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Plan of Correction POC Licensee agrees to conduct training on care and supervision for staff by POC due date.
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This requirement was not met as evidenced by:
Based on interviews Licensee did not provide care and supervision to C1 which poses an imediate health, safety and personal rights risk to clients in care.
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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