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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208938
Report Date: 06/10/2022
Date Signed: 06/10/2022 12:47:20 PM

Document Has Been Signed on 06/10/2022 12:47 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:PURPOSEFUL RESIDENTIAL CARE: ERIE PLACEFACILITY NUMBER:
157208938
ADMINISTRATOR:VICKERS, TYSONFACILITY TYPE:
735
ADDRESS:1308 ERIE STTELEPHONE:
(661) 742-6007
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 4DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator Tyson Vickers TIME COMPLETED:
01:00 PM
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On 6/10/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with House Manager Idell Ervin. Administrator was contacted and permission received to have staff complete the inspection and sign the report.

Facility staff was observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues.

Food supply was checked and appeared to be an adequate supply. All resident’s room toured and observed to be adequately furnished and lit. LPA toured bathrooms and observed Trash bins with lids and Hand washing signs. LPA observed shared resident’s beds to be at least 6 feet apart. LPA checked residents’ locked medications. 30-day PPE supplies were observed. At 12:15PM LPA observed Fire extinguisher was expired with a service date of 5/26/2021.

Staff records were reviewed for good health and infection control training. Two out of four residents’ records reviewed to have updated emergency contact information. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.


LPA is requesting the following documents be submitted to the Fresno CCL office by 6/17/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC
309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E),Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020. An exit interview was conducted with Staff. Report signed on-site by Administrator and printed copy provided with Appeal Rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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 06/10/2022 12:47 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 06/10/2022 at 12:21 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: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the
protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1. Fire extinguisher was expired
with a service date of 5/26/2021, which poses an immediate health, safety, or personal rights risk to persons in care..
POC Due Date: 06/10/2022
Plan of Correction
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Licensee to have fire extinguisher serviced and submit pictures as proof of POC. **Fire Extinguisher was served during inspection. POC is cleared. *******
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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022


LIC809 (FAS) - (06/04)
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