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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 03:16:29 PM


Document Has Been Signed on 08/07/2024 03:16 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) 301-0809
CITY:BAKERSFIELD, CASTATE: CAZIP CODE:
93309
CAPACITY:4CENSUS: 4DATE:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Administrator Breatrice VillegasTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette arrived at the facility unannounced to conduct a Case Management for an incident that occurred on 07/11/24. LPA met with Administrator Beatrice Villegas.

LPA interviewed Administrator. LPA obtained reviewed video and copies of the video of the incident. LPA obtained copies of staff interviews facility conducted. Administrator stated there were 4 staff on duty during the incident. LPA obtained a copy of the staff schedule. Administrator stated Staff 1 was removed from the facility after the incident.

After reviewing written statements from staff and interviewing Administrator, S1 pepper sprayed C1.

Refer to Bakersfield Police Department report # 24-144307.

An immediate Civil Penalty is being assessed. The issuance of additional civil penalties is pending and currently under review. The details of additional civil penalties will be outlined in a future report, if any.

Refer to 809D.

A copy of this report was provided to Administrator with plan of correction and appeal rights.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
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 03:16 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: VALLEY RESIDENTIAL SERVICES
FACILITY NUMBER: 157206728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation,
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Plan of Correction POC Licensee agrees to conduct a CPI training for all staff and will submit training by POC due date 8/16/24
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ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement was not met as evidenced by Licensee did not ensure the personal rights of C1 by S1 spraying C1 with pepper spray which poses an immediate health safety and or personal rights risk to clients 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
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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