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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208251
Report Date: 06/03/2022
Date Signed: 06/03/2022 10:11:42 AM

Document Has Been Signed on 06/03/2022 10:11 AM - 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:OLLIVIER, REBECCA AFACILITY TYPE:
772
ADDRESS:721 8TH STTELEPHONE:
(661) 326-9700
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93304
CAPACITY: 14CENSUS: 9DATE:
06/03/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Program Director Ronald CordyTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst LPA conducted a Case Management to follow up on incident reports that occurred on 1/30/22, 3/11/22, and 4/15/22. LPA was met by Staff Deborah Brown and discussed the purpose of the visit. Program Director Ronald Cordy met with LPA to assist with the case management.

LPA reviewed records for R1, R2, R3 and R4. Facility filed police reports regarding the AWOLS from the facility. After reviewing records R1 and R2 were unable to leave the facility unassisted and require supervision.

Deficiencies are being cited based on LPA's interviews conducted and record review in accordance with the CCR Title 22. See LIC 809D. Civil Penalties were issued.

An exit interview was conducted with Program Director Ronald Cordy a copy of this report with Plans of Corrections and appeal rights was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2022
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 06/03/2022 10:11 AM - It Cannot Be Edited


Created By: Shawna Doucette On 06/03/2022 at 09:59 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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2022
Section Cited
CCR
81078(a)

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81078 RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Licensee did not provide supervision for R1 and R2 which physician's report states
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Plan of Correction POC Licensee agrees to devolop a policy regarding this regulation and complete training by POC due date. Civil Penalties were issued.
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are not allowed to leave facility. This poses an immediate health, safety or personal rights risk to residents 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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022


LIC809 (FAS) - (06/04)
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