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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206585
Report Date: 05/18/2024
Date Signed: 05/18/2024 11:26:34 AM

Document Has Been Signed on 05/18/2024 11:26 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:AIMES JADEFACILITY NUMBER:
157206585
ADMINISTRATOR/
DIRECTOR:		GRAVES, SANDRAFACILITY TYPE:
735
ADDRESS:3151 JADE AVETELEPHONE:
(661) 327-3332
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 4CENSUS: 3DATE:
05/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Sandra GravesTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA met with Administrator Sandra Graves. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Administrator.

A tour of the facility was conducted with the Administrator. The residence was set at 75 F temperature and free of passageway obstructions inside and outside.

LPA Doucette observed 4 bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 108.7 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Knives were stored in a locked closet. Medications were stored in a locked closet. Cleaning supplies were unlocked in cabinet in laundry room and locked in a cabinet in garage. Smoke detectors and carbon monoxide detectors were checked and operating. Facility has a pull station fire alarm. Fire extinguishers were charged and had service dates of 1/15/24. Fire drill was last completed on 4/6/24.

LPA observed a self latching gate on the outside of the residence. There was shaded outdoor seating for the residents.

Resident, medication and staff records were reviewed and found to be complete. Current first aid and CPR were on file for staff.

Refer to 809D

An exit interview was conducted with the Administrator. A copy of this report with appeal rights and plan of correction was discussed and left with the Administrator, Sandra Graves, whose signature on this form confirm receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2024
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 05/18/2024 11:26 AM - It Cannot Be Edited


Created By: Shawna Doucette On 05/18/2024 at 11:18 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: AIMES JADE
FACILITY NUMBER: 157206585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 in Licensee did not have cleaning supplies in laundry room cabinet locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2024
Plan of Correction
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Licensee agrees to keep cleaning supplies locked and train staff on ensuring cabinet with cleaning supplies is locked. Cabinet was locked during visit and staff was trained on keeping the cabinet locked. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2024


LIC809 (FAS) - (06/04)
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