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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208853
Report Date: 06/09/2022
Date Signed: 06/09/2022 01:31:16 PM

Document Has Been Signed on 06/09/2022 01:31 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:STREBOR HOMEFACILITY NUMBER:
157208853
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:15730 STREBOR DRIVETELEPHONE:
(661) 695-9278
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 4CENSUS: 4DATE:
06/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Administrator Shannon SaysonTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst LPA conducted a Case Management to follow up on an incident reports on 12/08/21. LPA was met by Staff Lisa Keller and discussed the purpose of the visit. Administrator Shannon Sayson responded to the facility to assist with the case management.

LPA interviewed staff and reviewed records and obtained copies.


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

An exit interview was conducted with Administrator Shannon Sayson 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: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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 06/09/2022 01:31 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/09/2022 at 01:09 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: STREBOR HOME
FACILITY NUMBER: 157208853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited
CCR
80065(f)(1)

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80065 Personnel Requirements (f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (1) Principles of nutrition, food preparation and storage and menu planning.
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Plan of Corrections POC Licensee agrees to provide staff training on food preparation by POC due date. POC cleared during visit.
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This requirement was not met as evidenced by: Licensee did not ensure C1's drink was at a safe temperature to consume causing C1's mouth to be burned which poses an immediate health, safety and personal rights risks to clients 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: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022


LIC809 (FAS) - (06/04)
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