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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206907
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:39:50 PM

Document Has Been Signed on 03/12/2024 02:39 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: 59DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Administrator, Nancy MantianoTIME COMPLETED:
02:22 PM
NARRATIVE
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Licensing Program Analysts (LPA) D. Williams and L. Padgett conducted a Case Management. LPA's met with Administrator, Nancy Montiano and discussed the purpose of the visit.

LPA's reviewed facility roster and 24 out of 59 clients who are 60 years of age or older, which is approximately 41% of their census. Per the Title 22 Regulation a facility with a capacity of more than 6 and that has a population of 60 years of age or older that exceeds 25% of the current census requires an exception to be approved by the Department.

According, to the Administrator letters of support will have to be obtained from the client's representatives.

Based on record review and interviews a Deficiency is being cited on the attached LIC 809D page.

POC was reviewed and discussed with Administrator.

An exit interview was conducted and a copy of this report and appeal rights was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
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)
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Document Has Been Signed on 03/12/2024 02:39 PM - It Cannot Be Edited


Created By: Darius Williams On 03/12/2024 at 01:08 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
85068.4(g)

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(g) If acceptance or retention of an individual 60 years of age or older would result in the ... 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. ...
This requirement was not evident by:
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Licensee has agreed to create a step by step plan to get new LIC 602A's, Letters of support, Needs and Service, and other required documents for all clients over 60 years of age. Licensee will submit this plan to the Department by POC due date of 3/26/2024.
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Based on LPA record review, the Licensee did not ensure age exceptions were approved by the Department to accept and retain persons of 60, which poses a potential health and safety risks to persons in care.
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Ultimately, Licensee will have to submit these documents to the Department and request an age exception.

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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: 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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