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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206777
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:44:16 AM

Document Has Been Signed on 02/02/2023 11:44 AM - 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:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Administrator Terrence Hardge via telephone and Staff Jacqueline Lamb TIME COMPLETED:
12:00 PM
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On 02/2/23, 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, staff 1 (S1). Staff 2 (S2) Jacqueline Lamb arrived shortly. Administrator Terrence Hardge was called and authorized staff to receive and sign report. LPA conducted tour with S2. Three clients present during tour.

Upon entry facility staff was observed with 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 COVID-19 related signs and cough etiquette postings in facility. LPA observed fire extinguisher purchased date: 07/24/22. LPA observed a small amount of PPE supplies. 30 days PPE supplies storage in a central location. 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. LPA checked clients’ locked medications. At 10:32 AM, LPA and S2 observed cleaning chemicals stored unlock in hall cabinet. At approximately 10:37 AM, LPA and S2 observed tools stored in garage unlock. The exterior tour was conducted. Side gate was self-closing and free of obstruction. 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: 02/08/23. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610D. A copy of this report and appeal rigths was provided to S2.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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 02/02/2023 11:44 AM - It Cannot Be Edited


Created By: Mai Yang On 02/02/2023 at 11:22 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: DESTINY HOUSE
FACILITY NUMBER: 157206777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Buildings 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, at 10:32AM LPA and S2 cleaning chemicals stored in hallway cabinet unlock while three ambulatory clients were present in the living room. At 10:37AM, LPA and S2 observed an automatic drill stored next to a tool bag with tools on the garage on the counter unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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S2 immediately locked hallway cabinet. S2 immediately removed and locked tool bag with tools in kitchen cabinet. POC clear during visit.
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: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
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