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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208251
Report Date: 08/26/2024
Date Signed: 08/26/2024 01:54:00 PM

Document Has Been Signed on 08/26/2024 01:54 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:FREISE HOPE HOUSEFACILITY NUMBER:
157208251
ADMINISTRATOR/
DIRECTOR:		OLLIVIER, REBECCA AFACILITY TYPE:
772
ADDRESS:721 8TH STTELEPHONE:
(661) 326-9700
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY: 14CENSUS: 8DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Tina HealyTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst Shawna Doucette (LPA) arrived at the facility unannounced to conduct a Required Annual inspection. LPA was met by Administrator Tina Healy.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Kitchen toured, and was clean and safe for food preparation. Food supply checked, LPA observed a two day perishable and 7 day non perishable. Resident rooms checked. LPA observed an adequate supply of linen. Facility has two water heaters. Hot water measured at 114 and 127.3 degrees F. Facility was set at 72 F. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 06/17/2024. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has a pull station fire alarm and sprinkler system. Last fire drill conducted 7/24/2024. All cleaning supplies are locked and secured in a storage cabinet. Medications were locked in a medication room.

LPA reviewed resident and staff records. LPA reviewed medications. R1 missed a medication on 8/23/24. Facility has a centrally stored log however it does not list a start date. Facility has over the counter medications for residents however residents do not have a PRN order signed by the doctor for the medication. Facility medication technician stated its the "house supply". LPA obtained copies of medication issues.

An exit interview was conducted with the Administrator and a copy of this report with plans of correction and appeal rights were provided.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 08/26/2024 01:54 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/26/2024 at 11:21 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: FREISE HOPE HOUSE
FACILITY NUMBER: 157208251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(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, the licensee did not comply with the section cited above in 1 out of 2 water heaters measured at 127.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Licensee agrees to submit a photo of the water temperature measuring in between 105 F to 120 F by POC due date 08/27/24.
Type A
Section Cited
CCR
81075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in R1 was not administered medication on 08/23/24, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Licensee agrees to conduct a medication staff training by POC due date 09/06/24
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/26/2024 01:54 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/26/2024 at 11:22 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: FREISE HOPE HOUSE
FACILITY NUMBER: 157208251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in all residents have over the counter medication be given that are PRN and Routine medications without a doctors prescription which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to submit copies of prescription with clear instruction for all PRN or Routine over the counter medications for 3 residents by POC due date 08/30/24
Type B
Section Cited
CCR
81075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have start date for medications and Licensee does not have over the counter medications logged for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to submit centrally stored logs for 3 residents in care showing start dates and over the counter prescribed medicatons by POC due date 08/30/24
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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