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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206719
Report Date: 11/08/2023
Date Signed: 11/08/2023 07:43:28 PM


Document Has Been Signed on 11/08/2023 07:43 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:PARK RCFE, THEFACILITY NUMBER:
157206719
ADMINISTRATOR:MALONE, CATHYFACILITY TYPE:
740
ADDRESS:311 GARNSEY AVENUETELEPHONE:
(661) 283-4160
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY:9CENSUS: 5DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:17 PM
MET WITH:Licensee, Cathy MaloneTIME COMPLETED:
05:10 PM
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Licensing Program Analyst conducted an Annual Inspection visit. LPA Williams met with Licensee, Cathy Malone and discussed the purpose of the visit.

LPA Williams toured the facility with Administrator.

The kitchen was sanitary and in good repair. There were 2 days of perishable food and 7 days nonperishable food.

The dining and living room had seats to accommodate all residents. The facility thermostat reflected 76 degrees Fahrenheit (F).

LPA Williams observed five bedrooms. Each bedroom had a bed, with required linens, night stand, dresser, chairs, and working light. All bedrooms had space for residents.

Two bathrooms were observed. There were grab bars and seating available for resident use.

Smoke detectors and carbon monoxide detectors were present and operational. First aid kit was present and had all required items.

LPA observed medications and chemicals to be locked and inaccessible to residents

*Continued on LIC 809C*
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 11/08/2023
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The backyard had a covered shaded area for resident use. There is no pool on the premises.

LPA reviewed three client files and two employee files.

LPA observed the following deficiencies during the visit:

1) In a cupboard thats in the same hallway as the visitor bathroom, LPA observed the following items stored together; chips, various canned food, fruit cups, pine sol cleaning solution, GAIN detergent, and Clorox cleaning wipes.

2) In the main bathroom near the living room, LPA observed the tub to be discolored and have grime. The caulking around the tub was black and grey. Finally, the tub stopper was disjoined from the tub and hanging.


LPA requested the following documents be provided to the Department: Liability Insurance, LIC 500 and LIC 308.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/08/2023 07:43 PM - It Cannot Be Edited

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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2023
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met evident by:
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Licensee agreed to change the caulking and repair the tub by POC due date of 11/22/2023.
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Based on observations, the Licensee did not ensure the tub was free of grime and in good repair, which poses a potential health risk for persons in care.
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Type B
11/10/2023
Section Cited
CCR87309(c)

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(c) The items specified in (a) above shall not be stored in food storage areas or in storage areas used by or for clients.
( (a) states the items are Disinfectants, cleaning solutions, poisons, firearms).

This requirement was not met evident by:
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Licensee agreed to seperate the chemicals from food items by POC due date of 11/10/2023.
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Based on LPA observation the Licensee did not ensure, disinfectants and cleaning solutions were not stored with food, which poses a potential health and safety risk to persons 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: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3