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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 03/12/2024
Date Signed: 03/19/2024 12:21:43 PM

Document Has Been Signed on 03/19/2024 12:21 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:UNION VILLAFACILITY NUMBER:
157206907
ADMINISTRATOR:MONTIANO, NANCYFACILITY TYPE:
735
ADDRESS:1102 S. UNION AVE.TELEPHONE:
(661) 323-0768
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 89CENSUS: 59DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Nancy Montiano, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Lissett Padgett and Darius WIlliams arrived unannounced to conduct the Annual inspection. LPA's met with Administrator, Nancy Montiano (AD) and explained the purpose of the visit. Facility was toured with various staff.
Resident rooms contained required furnishings and lighting. LPA's observed required items in bathrooms. LPA's tested the hot water in three resident rooms with the following results: 129 degrees F, 124 degrees F, 75.4 degrees F . Resident hygiene supplies were properly stored and available. The kitchen was toured observed with necessary items and appliances and sharps/knives were properly stored.
LPA observed required food supply and paper products. LPA observed expired condiments in food pantry. Staff removed expired food items during this visit.
Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. At 10:20am LPA's observed barbed wire hanging low (about 5ft off the ground) on the perimeter fence. Staff explained barbed wire was installed for security measures.
First aid kits are located in office found to contain required items.
Fire Extinguishers are located throughout the facility and were serviced in 3/2024. Smoke and Carbon Monoxide detectors were present throughout facility and operational. Alarms are serviced by Secure Systems. LPA's conducted 6 resident and 6 staff file reviews. 1 staff file did not have documentation of initial training.
Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.
An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.
LPA is requesting the following documents be submitted to the Fresno CCL office by 3/22/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 03/19/2024 12:21 PM - It Cannot Be Edited


Created By: Lissett Padgett On 03/12/2024 at 01:31 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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Based on observation of barbed wire hanging low on perimeter fence, accessible to residents, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Licensee will remove resident's access to barbed wire.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of water temperature testing, water in resident rooms was 75.4, 124 and 129 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Licensee will conduct water temperature checks in all rooms to assure temperature is within 105-120 degrees F on a weekly basis. Licensee will consult with a plumber as to the best remedy for the temperature variations.
Licensee will immediately place warning signs on all faucets over 125 degrees F.
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 Pidgirny
LICENSING EVALUATOR NAME:Lissett Padgett
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/19/2024 12:21 PM - It Cannot Be Edited


Created By: Lissett Padgett On 03/12/2024 at 01:31 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above in that 1 of 6 staff files did not contain initial training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2024
Plan of Correction
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LIcensee will provided this LPA with documentation that Staff has completed intitial training.
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of expired condiments, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2024
Plan of Correction
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Licensee will removed all expired food items.
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 Pidgirny
LICENSING EVALUATOR NAME:Lissett Padgett
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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