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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206916
Report Date: 12/21/2022
Date Signed: 12/21/2022 01:37:51 PM

Document Has Been Signed on 12/21/2022 01:37 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:VILLAGE GARDENSFACILITY NUMBER:
157206916
ADMINISTRATOR:DIANNA L ELLISFACILITY TYPE:
740
ADDRESS:11910 CROCKETT COURTTELEPHONE:
(661) 587-1191
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 6DATE:
12/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Diana Ellis via TelephoneTIME COMPLETED:
01:50 PM
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On 12/21/22, during an Infection Control Inspection the following observations were made during facility tour by LPA Medina. LPA spoke to Administrator via telephone who verified that S1 is authorized to sign report

During inside facility tour, LPA Medina observed all medications cabinets to be unlocked and accessible to residents in care, cabinet locks observed to be inoperable. In the kitchen, LPA observed knives to be stored in unlocked dish washer and accessible to residents.

During outside facility tour, LPA observed pool to be surrounded by a 6-foot gate but to be unlocked and accessible to residents. S1 was unable to locate key to secure pool during visit.

Deficiencies cited on the attached 809D.

Exit interview conducted over telephone with Administrator and signed by caregiver. A copy of report will be emailed to Licensee and Administrator due to technical problems.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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Document Has Been Signed on 12/21/2022 01:37 PM - It Cannot Be Edited


Created By: Melinda Medina On 12/21/2022 at 01:04 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: VILLAGE GARDENS
FACILITY NUMBER: 157206916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited
CCR
87705(F)(1)

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(f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Licensee/Administrator to ensure that all knives and sharps are locked and secured and inaccessible to residents. POC to be submitted to Fresno Regional Office by due date.
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***This was not met as evidenced by LPA observed knives to be stored in unlocked dishwasher and accessible to residents.
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Type A
12/22/2022
Section Cited
CCR87705(f)(2)

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(f)The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain
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Licensee/Administrator to ensure that cabinet locks are operable and that all medications are locked, secured, and inaccessible to residents. POC to be submitted to Fresno Regional Office by due date.
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plants, gardening supplies, cleaning supplies and disinfectants.
***This was not met as evidenced by LPA observed all medication cabinets to be unlocked and accessible to residents in care, cabinet locks observed to be inoperable.
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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:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/21/2022 01:37 PM - It Cannot Be Edited


Created By: Melinda Medina On 12/21/2022 at 01:24 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: VILLAGE GARDENS
FACILITY NUMBER: 157206916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited
CCR
87705(e)

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(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.

***This was not met as evidenced by
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Licensee/Administrator to ensure that pool remains locked and secured at all times and inaccessible to residents. POC to be submitted to Fresno Regional Office by POC due date.
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LPA observed pool to be surrounded by a 6-foot gate but to be unlocked and accessible to residents. S1 was unable to locate key to secure pool during visit.
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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:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022


LIC809 (FAS) - (06/04)
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