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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206291
Report Date: 09/20/2021
Date Signed: 09/20/2021 02:32:22 PM

Document Has Been Signed on 09/20/2021 02:32 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:BRIDGE PROGRAM - BAKERSFIELDFACILITY NUMBER:
157206291
ADMINISTRATOR:SANDRA JIMENEZFACILITY TYPE:
772
ADDRESS:6744 EUCALYPTUS DRIVETELEPHONE:
(661) 363-8127
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 15CENSUS: 15DATE:
09/20/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Deanna BrownTIME COMPLETED:
03:32 PM
NARRATIVE
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Today, LPA L. Xiong was at the above facility to follow up on a Program certification review by Dept. of Health Care Services (DPCS) on July 26 - Sept. 2, 2021. I met with Deanna Brown, Program Director and informed her the purpose of the visit.

The following deficiencies are in violation of title 22 div. 6 CCR.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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 09/20/2021 02:32 PM - It Cannot Be Edited


Created By: Les Xiong On 09/20/2021 at 02:06 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: BRIDGE PROGRAM - BAKERSFIELD
FACILITY NUMBER: 157206291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2021
Section Cited
CCR
81068(a)

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81068 ADMISSION AGREEMENTS (a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.
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Program Director, D. Brown provided the corrected documents during the visit. No further correction necessary.
Type B
09/27/2021
Section Cited
CCR
81068.2(b)

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81068.2 NEEDS AND SERVICES PLAN
(b) For each client admitted, the licensee shall ensure that a written Needs and Services Plan is started prior to admission, and completed prior to or within 72 hours of admission, that must include:
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Program Director, D. Brown provided the corrected documents during the visit. No further correction necessary.
Type B
09/27/2021
Section Cited
CCR81068.3(d)(1)

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81068.3 MODIFICATIONS TO NEEDS AND SERVICES PLAN
(d) The program director or staff person specified in (a) above shall, with the client's participation, review the treatment/rehabilitation plan according to the schedule set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Section 532.2(c).
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Program Director, D. Brown provided the corrected documents during the visit. No further correction necessary.
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(1) Statement of specific treatment needs and goals.
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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:Les Xiong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2021


LIC809 (FAS) - (06/04)
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