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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206256
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:25:21 PM

Document Has Been Signed on 09/21/2023 12:25 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: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:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Administrator, Eric Coronado TIME COMPLETED:
12:39 PM
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On 09/21/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA contacted Administrator via telephone, introduced self, and stated the purpose of the visit. Administrator, Eric Coronado, arrived a short time later.

The purpose of this visit is to follow up on an incident report submitted to the Fresno CCL office. It was reported that on 09/02/2023 at approximately 5:20AM, facility staff became aware that R1 was no longer in the facility. R1 was located at approximately 6:50AM on foot approximately 14.9 miles away from the facility.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Eric Coronado, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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 09/21/2023 12:25 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/21/2023 at 11:55 AM
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: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the client's needs... This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detialing the steps the facility will take to ensure the requirements for section 80078 are met to the Fresno CCL office by the POC due date.
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Based on interview and record review, the Licensee did not meet the requirements of section 80078(a) when R1 was not provided supervision when R1 AWOL'd from the facility.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023


LIC809 (FAS) - (06/04)
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