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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157206907
Report Date: 10/20/2023
Date Signed: 10/20/2023 01:33:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/16/2023 and conducted by Evaluator Darius Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20231016150848
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:
10/20/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff, Yvonne AggasidTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility has pests.
Facility is in disrepair.
Facility does not have hot running water for the residents.
Facility does not provide a safe environment for the residents.
INVESTIGATION FINDINGS:
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LPA’s D. Williams and L. Padgett arrived at the facility unannounced for initial 10-day complaint inspection. LPA’s met with Staff, Yvonne Aggasid and discussed the purpose of the visit. Administrator was contacted via phone.

LPA’s conducted interviews and observations. LPA’s toured the facility with caregiver, Jesus Duya (CG).

In regard’s to the allegation, facility does not have hot running water, room 5 bathroom sink water reflected approximately 127.1 degrees Fahrenheit (F), room 46 reflected approximately 96.7 F, and room 47 approximately 91.1 degrees F, via LPA’s thermometers.

*Continued on LIC 9099-C*
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 24-AS-20231016150848
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: UNION VILLA
FACILITY NUMBER: 157206907
VISIT DATE: 10/20/2023
NARRATIVE
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In regard’s to the allegation, facility is in disrepair, LPA’s observed the roof overhang, that face the courtyard near the kitchen, to have sheetrock hanging from the ceiling with black spots near it. The sheet rock hanging down exposed the insulation. Additionally, the corner of the roof had rotted and warped wood, approximately spanning a length of 4 feet. LPA’s observed three screens to be ripped from halfway down the window. In room 7 and 34, LPA’s observed grime build up in the showers.

In regard’s to facility has pests, LPA Williams observed insects in the bathroom of room 24 scurry when the lights were turned on. LPA Padgett observed flies in the bedroom and bathroom of room 46.

In regard’s to the facility does not provide a safe environment for the residents, LPA’s observed three saw blades and a mallot, in the courtyard that were unsupervised and readily accessible to clients in care. Additionally, near room 27, lying in the dirt was 2 large rolls of barbed wire readily accessible to clients. Finally, the kitchen window pane, that faces with courtyard and is accessible to clients, was broken and not covered. According to Staff 1 the window panel had been broke since 10/19/2023.

Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, there the above allegations are found to SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099-D page. Additionally, a repeat civil penalty is being assessed, see attached LIC 421FC.

Plan of correction was reviewed and discussed.

An exit interview was conducted and a copy of this report and Appeal Rights were provided.

SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20231016150848
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: UNION VILLA
FACILITY NUMBER: 157206907
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2023
Section Cited
CCR
80088(e)(1)
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(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... hot water temperature of not less than 105 degrees F... and not more than 120 degrees F...

This requirement was not met evident by:
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Administrator agreed to have maintenance check water and change temperature as necessary, by POC due date.
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Based on observation, the Licensee did not ensure 2 of the rooms has water that delivered water over 105 F and 1 room whose water was over 120 F, which poses an immediate health and safety risk to people in care.
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Type A
10/21/2023
Section Cited
CCR
80087(a)
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(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 ws not met evident by:
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Maintenance placed a temporary cover on the glass pending its fix. The tools were moved to a locked location. The barbed wire was moved to a location inaccesbile to clients.
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The Licensee did not ensure, screens were repaired and showers were free of grime. Additionally the, kitchen window was not repaired and that tools and barb wire were inaccessible to clients in care, which poses an immediate health and safety risk to clients in care.
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The Licensee agreed to have the showers cleaned, sheet rock and window screens repaired by 10/27/2023. The Administrator will look into options to fix the rotting wood on the roof.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20231016150848
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: UNION VILLA
FACILITY NUMBER: 157206907
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
80087(a)(1)
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(a) The facility shall be clean, safe, sanitary and in good repair...(1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirmement was not met evident by:
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Administrator agreed to contact their contracted pest control and schedule an additional session. Administrator will notify the Department, of the appointment by POC due date of 10/27/2023.
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The Licensee did not ensure that two of eight rooms inspected were free of flies and insects, which poses a potential health and safety risk to persons in care.
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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.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5