<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208939
Report Date: 08/08/2022
Date Signed: 08/08/2022 12:10:57 PM


Document Has Been Signed on 08/08/2022 12:10 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:A GOLDEN HEART FAMILY CARE IFACILITY NUMBER:
157208939
ADMINISTRATOR:LIGON, JOCELYNFACILITY TYPE:
740
ADDRESS:13400 INDURAN DRTELEPHONE:
(661) 679-6410
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 6DATE:
08/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee Michelle LigonTIME COMPLETED:
12:30 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
Licensing Program Analysts (LPA) Shawna Doucette and Vadim Gorban contacted the facility to commence a complaint investigation. During the course of the investigation, LPA's were unable to review complete records for R1.

LPA interviewed staff and attempted to review R1's file. Licensee stated she gave the file to the placement agency and only has R1's 602. While touring the facility a staff room was observed in the garage and Licensee was unable to provide copy of fire clearance. Facility sketch was not observed to be posted in the facility.

See 809D for deficiency. Civil Penalties were issued for added staff bedroom in garage that is not fire cleared.

An exit interview was conducted and a copy of this report with appeal rights were provided to Licensee.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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 08/08/2022 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: A GOLDEN HEART FAMILY CARE I
FACILITY NUMBER: 157208939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2022
Section Cited

1
2
3
4
5
6
7
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by adding a staff bedroom in the garage that is not fire cleared which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
08/12/2022
Section Cited

1
2
3
4
5
6
7

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Licensee did not
8
9
10
11
12
13
14
have a complete file (no admissions agreement, pre appraisal, needs and service plan ect) for R1 which poses a potential health, safety or personal rights risk to residents in care.
8
9
10
11
12
13
14
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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2