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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206777
Report Date: 05/26/2022
Date Signed: 06/06/2022 02:06:33 PM

Document Has Been Signed on 06/06/2022 02:06 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:DESTINY HOUSEFACILITY NUMBER:
157206777
ADMINISTRATOR:HARDGE, TAMERRAFACILITY TYPE:
735
ADDRESS:2433 WILLIAMS COURTTELEPHONE:
(661) 279-5053
CITY:ROSAMONDSTATE: CAZIP CODE:
93560
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Tamerra Hardge, Administrator via telephone and Staff Jacqueline LambTIME COMPLETED:
10:15 AM
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Amended Report

On 05/26/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Yolanda De Avila. Administrator Terrence Hardge was called and authorized staff Jacqueline Lamb to conduct tour and sign report. Staff Jacqueline Lamb arrived shortly and conducted tour with LPA. Three clients present during tour.

Upon entry facility staffs was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. LPA and DSP observed fire extinguisher purchased date: 07/25/20. LPA observed 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant. LPA observed trash bin with no lid in bathrooms. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in hall cabinet. LPA checked clients’ locked medications.

The exterior tour was conducted. Side gate was self-closing and free of obstruction. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/03/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, current administrator certificate, and control or property. A copy of this report and appeal rights was provided to staff and to Administrator via email.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
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)
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Document Has Been Signed on 06/06/2022 02:06 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/06/2022 01:57 PM


Created By: Mai Yang On 05/26/2022 at 09:24 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: DESTINY HOUSE
FACILITY NUMBER: 157206777

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
Based on observation, Fire Extinguisher has a service date of 07/25/2020, which poses an immediate health and safety risk to the residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, Administrator stated Fire extinguisher had been purchased within the previous year. However, LPA and DSP observed Fire extinguisher has a purchased date of 07/25/2020 which poses an immediate health and safety risk to the resident.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator stated Fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the date 05/27/22.
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:Mai Yang
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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