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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208951
Report Date: 11/12/2021
Date Signed: 11/15/2021 12:33:07 PM

Document Has Been Signed on 11/15/2021 12:33 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:BUENA VISTA MANOR ARF INC.FACILITY NUMBER:
157208951
ADMINISTRATOR:BAGUIO, MIAFACILITY TYPE:
735
ADDRESS:11126 VISTA DEL VALLE DRIVETELEPHONE:
(661) 885-7838
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 3DATE:
11/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Administrator Mia BaguioTIME COMPLETED:
11:43 AM
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On 11/12/21 Licensing Program Analysts (LPAs) L. Salazar and M. Yang arrived to the facility unannounced to conduct a Case Management visit. LPAs were greeted by Staff S1. LPAs stated purpose of the visit and allowed entry into the facility after COVID precautionary measures were taken.

LPAs toured the facility. Facility is a 4 bedroom / 2 bath house. LPAs observed 3 out of 3 residents in care at the time of the visit.

On 06/27/2021, it was reported that Resident R1 eloped from the facility in the middle of the night. LPA reviewed the physician report and Individual Performance Plan for R1. Documentation stated R1 is unable to leave the facility unattended. LPA reviewed a Bakersfield Police Report that stated R1 was an "at risk" individual that was missing from the facility for a period of time. This poses an immediate risk to residents in care.

Based on records review from and in accordance with the California Code of Regulations, Title 22, Division 6 Chapter 8, The following deficiency is cited on the attached 809-D.
A violation regarding care and supervision warrants an immediate civil penalty of $500 and is hereby assessed. See LIC 421IM.

An exit interview was conducted and Plans of correction were reviewed and developed with the Administrator. A copy of this report and appeal rights are being sent via email by next working day.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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 11/15/2021 12:33 PM - It Cannot Be Edited


Created By: Lisa Salazar On 11/12/2021 at 10:43 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: BUENA VISTA MANOR ARF INC.
FACILITY NUMBER: 157208951

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2021
Section Cited
HSC
1568(c)(3)

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ยง1548 Civil penalties; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations: (3) Absence of supervision, as required by statute or regulation.

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Administrator will provide additional supervision by scheduling additional staff. Administrator will submit staff schedules for November and December of 2021 at the beginning of each month.
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This requirement was not met as evidenced by records review of Bakersfield Police Department report stating R1 was an "at risk" individual missing from the facility. R1 was found approximately 1 mile away and 6 hours later. This poses an immediate risk to resident's in care. Civil Penalty is assessed.
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Administrator will have staff review Residents plan of care that outlines the condition and care needs of each resident. Administrator will send copies of staff signature's acknowledging that the Care plans have been provided and reviewed by all staff/caregivers.

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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: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


LIC809 (FAS) - (06/04)
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