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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206898
Report Date: 02/25/2022
Date Signed: 03/02/2022 07:16:59 AM

Document Has Been Signed on 03/02/2022 07:16 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:SPRUCE GARDENSFACILITY NUMBER:
157206898
ADMINISTRATOR:PONCE, BEATRIZ AFACILITY TYPE:
740
ADDRESS:13303 NANTUCKET PLACETELEPHONE:
(661) 829-2703
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 3DATE:
02/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Executive Assistant, Michelle Macias, TIME COMPLETED:
01:08 PM
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On 02/25/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a Health & Safety check on residents is care. LPA was greeted by Staff S1 and was allowed entry into the facility. LPA toured the facility and observed a 5 bedroom, 3 bathroom house.

LPA observed 3 out of 3 residents in care. Resident R1 was watching TV is living room and stated they were comfortable. Resident R2, who is on hospice, was sleeping in her bed. Resident 3, who is also on hospice, was in her room being fed by S1.

Facility has hospice waiver for 3. 2 out of 3 residents in care are receiving Hospice Care, LPA observed hospice care plan on file for both residents.

LPA reviewed resident and staff files and observed CPR certificate for S1. Fire extinguishers dated 08/26/21 and operating smoke detectors were observed. Current Emergency Disaster plan is posted along with other require posting.

LPA observed 2 out of 2 staff members to be present. Both have fingerprint clearances and associations to facility. Administrator on file (Staff S2) is no longer working at the facility as of 02/15/22. Current acting Administrator as of 02/24/22, is Stephanie Haro. Executive Assistant (EA) is in the process of becoming Administrator. LPA called the Administrator certification division and confirmed the application for EA was submitted on 02/01/22 and is in pending status.


(Continued on 809-C)
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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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: SPRUCE GARDENS
FACILITY NUMBER: 157206898
VISIT DATE: 02/25/2022
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(Continued from 809)

Based on LPA Doucette's case management visit on 02/22/2022, and after further file review. EA was not associated to the facility at the time of that visit. A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D. A Civil Penalty is being assessed in the amount of $500.

Exit interview was conducted and appeal rights given. The plan of correction has been completed and cleared. Appeals Rights and a copy of this report were provided to EA.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/02/2022 07:16 AM - It Cannot Be Edited


Created By: Lisa Salazar On 02/25/2022 at 12:25 PM
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: SPRUCE GARDENS
FACILITY NUMBER: 157206898

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited
CCR
87355(e)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by LPA Doucette's observation and records review on 02/22/22. Civil Penalty is being assessed.
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Facility has associated Executive Assistant to the facility as of 02/24/22. **POC Cleared**
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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:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022


LIC809 (FAS) - (06/04)
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