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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206719
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:40:23 PM

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:PARK RCFE, THEFACILITY NUMBER:
157206719
ADMINISTRATOR:MALONE, CATHYFACILITY TYPE:
740
ADDRESS:311 GARNSEY AVENUETELEPHONE:
(661) 283-4160
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:9CENSUS: 7DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Cathy MaloneTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Dana Dotson. Administrator Cathy Malone responded to the facility and LPA discussed the purpose of the visit. LPA and Administrator began the tour at the front entrance of the facility.

Facility staff were not wearing masks when LPA entered the facility. Facility staff did not check temperature upon entry. Facility did not have visitor log. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors outside of door. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and a seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door. LPA observed staff to be cleaning however cleaning supplies were left unattended to complete other duties. LPA observed the following personal protective equipment; gloves and masks.

Resident’s files have updated emergency contact information.

See attached 809d. Civil Penalties were issued.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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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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: PARK RCFE, THE
FACILITY NUMBER: 157206719
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs...


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 by having 1 staff for 7 dementia residents where LPA observed cleaning supplies to be left out while staff was attempting to also attend to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2021
Plan of Correction
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Licensee will submit a tentative schedule to include additional staffing during peak hours of the day to CCL by POC due date, until additional staff can be hired.
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 PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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