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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208910
Report Date: 06/21/2022
Date Signed: 06/24/2022 07:32:17 AM

Document Has Been Signed on 06/24/2022 07:32 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:VILLA HERMOSAFACILITY NUMBER:
157208910
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:10808 VILLA HERMOSA DRTELEPHONE:
(661) 203-2116
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 4CENSUS: 3DATE:
06/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Program Director, Lester Manigque via telephoneTIME COMPLETED:
03:30 PM
NARRATIVE
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On 06/21/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management inspection based on information received. LPA was greeted by Administrator and Staff S1, explained the purpose of the visit as was allowed entry. COVID precautionary measures were taken at the time of entry.

LPA conducted interviews on a complaint investigation visit on 05/31/2022. Interviews revealed an allegation that Resident R1 was not receiving their P&I funds. LPA requested and obtained copies of the P&I logs for R1. Records revealed that R1 did not receive their monies for the month of May 2022. This poses an potential risk to residents in care.

Based on records reviewed, per California Code of Regulations, Title 22, Division 6, the following deficiency is being cited on the attached 809-D.

An exit interview was conducted with Program Director via telephone, who gave permission for Program Supervisor to sign report. A copy of this report and appeal rights were provided to Program Supervisor at the time of visit.


SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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 06/24/2022 07:32 AM - It Cannot Be Edited


Created By: Lisa Salazar On 06/21/2022 at 02:23 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: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
85072(b)(7)

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85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights.(7) To possess and control his/her own cash resources.
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Program Director provided all P&I monies due to Resident R1 on 06/01/22. R1's account has been set up on a debit card through US Bank. Monies are provided through payee, New Leaf. LPA observed debit card at the time if visit. *** POC cleared***
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This requirement was not met as evidenced by LPA's interview with resident and LPA's observation of R1's P&I logs evidencing R1 was not given their money in the month of May 2022.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022


LIC809 (FAS) - (06/04)
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