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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 11/03/2023
Date Signed: 11/03/2023 01:35:00 PM

Document Has Been Signed on 11/03/2023 01:35 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: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: 64DATE:
11/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Staff, Yvonne AggasidTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst conducted a case management visit. LPA met with Staff, Yvonne Aggasid and discussed the purpose of the visit.

On 10/20/2023, LPA Williams and LPA Lissett Padgett observeded, boards over the windows of 3 occupied rooms. According to Bakersfield Fire inspector, boards over the window are a violation of the California Fire Code. If not corrected the violation will have a direct and immediate health and safety risk to person's in care. Additionally, a civil penalty of $1000 is being assessed, for a repeat violation.

Additionally, LPA Williams observed a black fence being constructed around the property. The Department was not notified of the alteration to the facility.

Based on observations and interviews, deficiencies are being cited on the attached LIC 809D page.

POC's were reviewed and discussed.

An exit interview was conducted and a copy of this report will be provided via e-mail.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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 2
Document Has Been Signed on 11/03/2023 01:35 PM - It Cannot Be Edited


Created By: Darius Williams On 11/03/2023 at 09:52 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: UNION VILLA
FACILITY NUMBER: 157206907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2023
Section Cited
CCR
80020(a)

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(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement was not met evident by:
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The screwed in boards over the windows were removed in the presence of the LPA. POC cleared on site.
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Licensee did not ensure to follow fire codes, by boarding up three windows, which poses an immediate health and safety risk to people in care.
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Type B
11/08/2023
Section Cited
CCR80086(a)

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(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirment was not met evident by:
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Licensee agreed to read 80086 regulation in its entirety and submit a signed document to the Department verifying they understand the regulation by POC due date 11/8/2023.
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Licensee did not ensure to notify the Department regarding the installation of a new black iron fence.
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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:Serigy Pidgirny
LICENSING EVALUATOR NAME:Darius Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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