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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206776
Report Date: 05/26/2022
Date Signed: 05/26/2022 12:18:14 PM

Document Has Been Signed on 05/26/2022 12:18 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:EUCALYPTUS HOUSEFACILITY NUMBER:
157206776
ADMINISTRATOR:GREENHALGH, STELLAFACILITY TYPE:
735
ADDRESS:7708 SPROAT WAYTELEPHONE:
(661) 282-5687
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Billie Goodman, Lead StaffTIME COMPLETED:
12:35 PM
NARRATIVE
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On 5/26/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. Administrator was unavailable for inspection.
LPA conducted tour with staff and did not observed any obstructions. No fire issues observed. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and residents do not share bedrooms. LPA checked residents’ medications. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Resident files have updated emergency contact information. Administrator certificate is valid.

The following deficiencies were observed:
1. Storage unit in patio where two shovels, two metal rakes, one garden hoe, and one hand cultivator tool are kept was observed unlocked and accessible.
2. Bedroom #1 and 2, living room, and office window screen frames observed with a bent side. Bedroom #4's left side window screen missing. Bedroom #1 and 2 window curtain rods observed bent. Right side exterior fire exit gate observed unable to open and close with ease. Left side exterior fire exit gate observed with missing pull string, gate is not latching when closing, and gate is not opening and closing with ease.
3. S1 does not have a signed health assessment report and has been working since 9/15/2020.

The following updated forms to be sent to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D (new revision)

Deficiencies are being cited based on LPA's observations in accordance with the California Code of Regulations, Title 22, see LIC809D. Exit interview conducted. A copy of this report and appeal rights were given to Lead staff Billie Goodman, whose signature confirms receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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
Document Has Been Signed on 05/26/2022 12:18 PM - It Cannot Be Edited


Created By: Malia Thao On 05/26/2022 at 11:23 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: EUCALYPTUS HOUSE
FACILITY NUMBER: 157206776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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. Storage unit in patio where two shovels, two metal rakes, one garden hoe, and one hand cultivator tool are kept was observed unlocked and accessible, which poses an immediate safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator will submit proof of signed statement attesting to all listed items above removed from the facility to CCL by POC due date.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/26/2022 12:18 PM - It Cannot Be Edited


Created By: Malia Thao On 05/26/2022 at 11:23 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: EUCALYPTUS HOUSE
FACILITY NUMBER: 157206776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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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4
Based on observation, the licensee did not comply with the section cited above. Bedroom #1 and 2, living room, and office window screen frames observed with a bent side. Bedroom #4's left side window screen missing. Bedroom #1 and 2 window curtain rods observed bent. Right side exterior fire exit gate observed unable to open and close with ease. Left side exterior fire exit gate observed with missing pull string, gate is not latching when closing, and gate is not opening and closing with ease. All of which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Administrator will repair or replace window screens for bedrooms #1 and 2, living room, and office; install new window screen for bedroom #4; install new curtain rods in bedrooms #1 and 2; repair right side exterior fire exit gate to open and close with ease; install new pull string and latch for left side exterior fire exit gate and gate to be repaired to open and close with ease by POC due date. LPA will return for POC visit.
Type B
Section Cited
CCR
80065(g)(2)
80065 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S1 did not have signed health assessment report and has been working since 9/15/2020, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Administrator will have S1 complete or provide a signed health assessment report by POC due date. LPA will return for POC visit.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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