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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208938
Report Date: 08/24/2023
Date Signed: 08/24/2023 01:59:25 PM

Document Has Been Signed on 08/24/2023 01:59 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: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: 3DATE:
08/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:37 AM
MET WITH:Licensee Adonica VickersTIME COMPLETED:
02:15 PM
NARRATIVE
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On 8/24/2023, Licensing Program Analysts (LPAs) K.Kaur and M. Flores arrived unannounced for complaint inspection and conducted a case management. LPAs were allowed entry by staff. Licensee was contacted and arrived a short time after.

At 11:15AM LPAs toured the facility and observed the laundry room door and garage door to be unlocked. Unlocked garage contained chemicals and bleach. At 12:02 PM LPA's observed resident files to be missing needs and services plans.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. An Immediate civil penalty of $250 assessed for repeat violation.

An exit interview was conducted with Licensee Adonica Vickers discussing the plan of corrections. Report signed on-site; printed copy provided with 809D page and appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/24/2023 01:59 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 08/24/2023 at 11:50 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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
CCR
80087(g)

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(g) 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:
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Licensee to submit plan in writing to implement a process to lock chemicals or move to a locked area.
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LPA observed unlocked chemicals and bleach in garage.
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Type B
09/07/2023
Section Cited
CCR85068.2(b)

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85068.2 Needs and Services Plan (b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include:

This requirement is not met as evidenced by:
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Licensee to complete Needs and Services Plan for all residents and submit copies to CCLD by due date. Licensee to ensure that prior to admission of a new resident a Needs and Services Plan will be completed.
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LPAs observed during file review, resident's files did not include a Needs and Services Plan.
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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: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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