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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206728
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:15:10 PM

Document Has Been Signed on 08/31/2021 03:15 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:VALLEY RESIDENTIAL SERVICESFACILITY NUMBER:
157206728
ADMINISTRATOR:VILLEGAS, BEATRICEFACILITY TYPE:
735
ADDRESS:5808 EDGEMONT DRTELEPHONE:
(661) 832-0214
CITY:BAKERSFIELD, CASTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Caregiver, Dawona Howard and Administrator, Beatrice VillegasTIME COMPLETED:
12:10 PM
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On 08/31/2021, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit and was granted entry to the facility by Caregiver, Dawona Howard. Administrator, Beatrice Villegas was contacted via telephone. LPA received verbal permission to conduct the facility tour with Caregiver until Administrator arrived. Administrator arrived a short time later.

Facility tour conducted with Caregiver. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathroom did have a trash cans with lid. Hand washing posters were observed by the bathroom sink. LPA observed a hole in the window screen in bathroom 1. Bedrooms were checked and beds are six feet apart. LPA observed 2 blinds missing from the window in bedroom 2. LPA observed a hole in the window screen in the Den area.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. LPA observed the kitchen light cover to be cracked. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Facility staff was observed with mask on. Residents wear masks when away from the community. 2 out of 2 resident files have updated emergency contact information.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: VALLEY RESIDENTIAL SERVICES
FACILITY NUMBER: 157206728
VISIT DATE: 08/31/2021
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Based on today's visit, a deficiency is being cited in the area evaluated and listed on the 809-D according to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. A Plan of Correction was developed and reviewed with the Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Beatrice Villegas via email and an electronic read receipt confirms receiving these documents. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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Document Has Been Signed on 08/31/2021 03:15 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/31/2021 at 11:58 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: VALLEY RESIDENTIAL SERVICES
FACILITY NUMBER: 157206728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087: Buildings and Grounds: (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 when LPA observed the kitchen light cover to be broken, blinds missing in bedroom 2, and holes in the window screens in bathroom 2 and the den area, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2021
Plan of Correction
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Licensee agreed to repair the light cover, screens, and blinds. Licensee agreed to submit pictures of the repairs as proof that the corrections were made to the Fresno CCL office by 09/30/2021.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2021


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