157208910-3-8-2023-24-AS-MYAG-CPR2CB-20230308161629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157208910
Report Date: 03/03/2023
Date Signed: 03/08/2023 04:17:44 PM

Document Has Been Signed on 03/08/2023 04:17 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	VILLA HERMOSA		FACILITY NUMBER:	157208910
ADMINISTRATOR:	WILLIAMS, DONTE		FACILITY TYPE:	735
ADDRESS:	10808 VILLA HERMOSA DR		TELEPHONE:	(661) 203-2116
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY: 4		CENSUS: 4	DATE:	03/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Lester Manigque , Program Director		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/1/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. COVID precautionary measures were taken at the time of entry. LPA met with Regina Browden, staff. Program Director (PD), Lester Manigque was called and arrived shortly and conduct tour with LPA. Two clients were present during the inspection. The tour started in the common areas into the kitchen, resident's rooms, and bathrooms. LPA observed COVID-19 related signs. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Refrigerator temperature maintained at 37 degrees F and freezer temperature at 0-degree F. Medications are kept locked medication drawer in the kitchen. Cleaning supplies and chemicals are kept in locked under kitchen sink.At approximately 01:37PM, LPA and staff observed knife unlock in kitchen drawer. An adequate supply of perishable and non-perishable food was observed to be properly stored and labelled. Carbon monoxide and smoke detectors were tested and observed to be operational. Fire extinguisher was observed with a service date of: 07/7/22. Clients' bedrooms were toured next and observed to be adequately furnished with bed, dresser, and adequate lightning. Bathrooms were properly equipped, and the hot water temperature was tested at 105 degrees F. Trash can with lid and hand washing postings was observed. Laundry area was observed to be operational. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. First aid kit was observed and contained all required items. At approximately 1:50PM, LPA and PD observed two toolboxes with tools and paint cans unlock in garage. Outside of facility toured. Exterior toured and LPA observed side gate to be self-closing and self-latching. Fire drill last completed on 2/24/23.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VILLA HERMOSA	FACILITY NUMBER: 157208910
	VISIT DATE: 03/03/2023

NARRATIVE

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All clients’ file reviewed to have update emergency contacts, Admission agreement, and Pre-Appraisal forms. A sample of staff's files were also reviewed. Staff files were observed to have current First Aid/CPR. Staff are fingerprinted clear and associated to the facility.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 3/9/23. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, control of property, and current Administrator certificate. A copy of this report and appeal rights was provided to the Program Director.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2023 04:17 PM - It Cannot Be Edited

Created By: Mai Yang On 03/03/2023 at 03:17 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: VILLA HERMOSA	FACILITY NUMBER: 157208910
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

80087(g) Buildings and Grounds Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, when LPA and staff observed knives in kitchen drawer unlock. In the garage, LPA and PD observed two toolboxes filled with multiple tools, multiple paint cans, and a shovel in the garage unlock which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/03/2023
	Plan of Correction
1 2 3 4	The staff immediately locked knife drawer. Program Director immediately removed toolboxes, paint cans, and shovel into locked cabinet in the garage. POC cleared during inspection.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

See Moua

LICENSING EVALUATOR NAME:

Mai Yang

LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC809 (FAS) - (06/04)

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