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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208854
Report Date: 11/25/2024
Date Signed: 11/25/2024 03:01:56 PM

Document Has Been Signed on 11/25/2024 03:01 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:HOUGHTON HOMEFACILITY NUMBER:
157208854
ADMINISTRATOR/
DIRECTOR:
SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:6444 HOUGHTON RDTELEPHONE:
(661) 827-8025
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 4CENSUS: 2DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:23 AM
MET WITH:House Manager Lereese DelouthTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst LPA Shawna Doucette arrived at the facility unannounced to conduct a required annual visit. LPA were granted entry by House Manager Lereese Delouth and explain the purpose of the visit. LPA contacted Administrator Shannon Sayson who responded to assist with the visit.

A tour of the facility was conducted with the House Manager. The residence was set at 70 F temperature and free of passageway obstructions inside and outside.

LPAs observed four bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean. Hot water temperature was measured 128.8 F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. Knives were stored in a locked drawer. Medications were stored in a locked medication cart. Cleaning supplies were in a locked cabinet in laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguishers were charged and had service dates of 8/5/24. Fire drill was last completed on 10/31/24. Facility has a pull station fire alarm. Facility has a sprinkler system.

There was outdoor seating for the residents. Pool gate lock was locked.

Resident, medication and staff records were reviewed. Current first aid and CPR were on file for staff.

Deficiencies were noted on the 809D.

An exit interview was conducted with the Administrator. A copy of this report, plan of correction and appeals rights were discussed and left with the Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 03:01 PM - It Cannot Be Edited


Created By: Shawna Doucette On 11/25/2024 at 01:03 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: HOUGHTON HOME

FACILITY NUMBER: 157208854

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(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) (interview) (record review)], the licensee did not comply with the section cited above in Licensee water termperature measured at 128.8 F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2024
Plan of Correction
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Licensee agrees to submit a phote of the water temperature measuring in between 105 F and 120 F by POC due date 11/26/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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