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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208938
Report Date: 07/02/2024
Date Signed: 07/03/2024 11:36:56 AM

Document Has Been Signed on 07/03/2024 11:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:PURPOSEFUL RESIDENTIAL CARE: ERIE PLACEFACILITY NUMBER:
157208938
ADMINISTRATOR/
DIRECTOR:		VICKERS, TYSONFACILITY TYPE:
735
ADDRESS:1308 ERIE STTELEPHONE:
(661) 742-6007
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93307
CAPACITY: 6CENSUS: 3DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH:Adonica Vickers, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst L. Padgett (LPA), conducted an unannounced annual visit to the facility. LPA stated the purpose of the visit and Care giver, Zanae Robinson granted entry to this LPA. House Manger, Niesha Payton (HM) was present and accompanied this LPA during the facility tour. Administrator (AD) Adonica Vickers was called and arrived shortly thereafter.

At the time of the visit, LPA observed 3 residents in the facility.

LPA observed that the kitchen was well maintained, with working lights and well maintained appliances. The knives were kept in a locked drawer. The kitchen counters and sink are free from debris. LPA observed a trash bin with the lid. LPA observed that refrigerator are well maintained and clean. LPA observed a 2 day perishable food supply. The kitchen cabinets are clean, organized, and had 7 days of non-perishable food. No expired food was observed. Fire extinguisher purchased on 7/12/23 with the correct pressure gauge as indicated on the meter.

Caregiver opened the locked medication cabinet for inspection. LPA observed medication cabinet contained medication bins for each resident, labeled and organized.

First aid kit was inspected and found to contain the required items.

LPA observed the dining room is well lit and clean. Dining table has seating for 3. The dining room has a sliding glass door that was clean and not obstructed.

In the living room, LPA observed television to be in a secure place. LPA observed sofa which can accommodate at least 5 people. The furniture was clean and in good condition.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938
VISIT DATE: 07/02/2024
NARRATIVE
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In the hallway that leads to the bedrooms, LPA observed, smoke detector and carbon monoxide detector installed. The smoke alarm and carbon monoxide detectors were tested by the AD and are functioning.

LPA inspected the hallway bathroom and observed that the bathroom is well maintained, well lit, toilet paper, paper towels, hand soap, a trash can with lid. Water temperature measured at 88.9 degrees F. The bathroom was observed to have non-skid floor, grab bars in shower and near toilet. The toilet was flushed and is functioning.

Laundry room has washer and dryer.

LPA observed that the garage is well maintained, free from obstructions and debris. The garage has locked storage cabinets for extra toiletries, cleaning supplies and PPE. Extra supply of meat and frozen food is stored in chest freezer in the garage.

This facility has 3 bedrooms.

LPA inspected resident bedrooms 1 and 3 with HM. LPA observed Bedrooms are a single bed, have good lighting. Required furniture is present and in good condition, the linens are in good condition. Window and screen in good condition. Closet stores the resident's clothing and personal belongings. Resident linens/towels are stored in resident bedrooms.

LPA observed that bedroom #2 is a single bedroom. The bedroom well lit. Windows and screens are in good condition. Bedroom has hospital bed and required furniture. Furniture and linens are free from stains and are well maintained. This bedroom has a private bathroom with covered trash bin, cabinets for toiletries, grab bars, and a shower bench. The toilet was flushed and is functioning. The water temperature measured at 100.4 degrees F.

LPA with HM inspected the backyard. LPA, observed that the backyard is well maintained, grass in good condition. Patio chairs and table observed under large patio umbrella, ready for use. The exterior walkways are free from obstructions and debris. Side gate with lock is maintained unlocked.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PURPOSEFUL RESIDENTIAL CARE: ERIE PLACE
FACILITY NUMBER: 157208938
VISIT DATE: 07/02/2024
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LPA reviewed residents and staff records with AD and found that all documents are in order and up to date.
LPA is requesting the following documents be submitted to the Fresno CCL office by 7/9/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610D) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lissett Padgett
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/03/2024 11:36 AM - It Cannot Be Edited


Created By: Lissett Padgett On 07/02/2024 at 11:20 AM
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: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when it was found that R1's ambulatory status is bedridden and this facility does not have a bedridden fire clearance. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Licensee has decided to retain the bedridden resident. Licensee agrees to submit the following documents to the Fresno CCL office by the POC due date: Letter requesting Bedridden Fire Clearance, LIC999 , LIC9054.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lissett Padgett
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2024 11:36 AM - It Cannot Be Edited


Created By: Lissett Padgett On 07/02/2024 at 11:20 AM
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: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
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 LPA observation of water temperature measured, bathroom 1 was at 88.9 and bathroom 2 was at 100.4, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2024
Plan of Correction
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Licensee will have their maintenance company assess and correct the water temperature in the bathrooms by the due date. Licensee will provide LPA with verification that the water temperature has been corrected.
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:Lissett Padgett
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


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