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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206728
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:14:03 PM

Document Has Been Signed on 08/07/2024 03:14 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/
DIRECTOR:		VILLEGAS, BEATRICEFACILITY TYPE:
735
ADDRESS:5808 EDGEMONT DRTELEPHONE:
(661) 301-0809
CITY:BAKERSFIELD, CASTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Staff Deanna Avila and Administrator Beatrice VillegasTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct the Required Annual Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by Staff Dianna Avila. Staff contacted Administrator Beatrice Villegas who responded to the facility to assist with the visit.

A tour of the facility was conducted with the Administrator. The residence was set at 76 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 107.6 F.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Knives were stored in a locked drawer. Medications were stored in a locked Medication closet. Cleaning supplies were in a locked cabinet in the garage. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguishers were charged and had service dates of 5/02/24. Fire drill was last completed on 06/25/24. Facility has a pull station fire alarm and a sprinkler system.

LPA observed a self latching gate on the outside of the residence. There was outdoor seating for the residents. Facility has a pool which is fenced and locked inaccessible to clients in care.

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

An exit interview was conducted with the Administrator and a copy of this report with plan of correction and appeal rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 03:14 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/07/2024 at 10:13 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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have an LIC 602 for C1 and C2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to submit copies of LIC 602's for C1 and C2 by POC due date 08/30/24.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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