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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209003
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:13:50 AM

Document Has Been Signed on 10/12/2022 10:13 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KOOTENAY COURTFACILITY NUMBER:
157209003
ADMINISTRATOR:DURAN, RONALDFACILITY TYPE:
735
ADDRESS:2808 KOOTENAY COURTTELEPHONE:
(661) 412-8548
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ronald Duran, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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On 10/12/22 at 8:40 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Administrator arrived a short time later. There were two staff and two residents present during the inspection.

Facility was observed clean and without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is valid.

The following deficiency was observed:
1. S1 did not have a completed health screening report and has been working since 1/30/21.

The following forms are to be submitted to CCL within 2 weeks:
LIC610D (new revision), LIC400

Deficiency is being cited based on LPA observations, record review, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report was given to Administrator Ronald Duran, whose signature confirms receipt of this report.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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 10/12/2022 10:13 AM - It Cannot Be Edited


Created By: Malia Thao On 10/12/2022 at 09:52 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: KOOTENAY COURT
FACILITY NUMBER: 157209003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(g)(2)
80065 Personnel Requirements
(g) All personnel, including the licensee, administrator and volunteers, shall be in good health, and shall be physically, mentally, and occupationally capable of performing assigned tasks.
(2) A health screening report signed by the person performing such screening shall be made on each person specified above, and shall indicate the following:

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. S1 did not have a completed health screening report and has been working since 1/30/21, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Administrator will submit proof of a completed health screening report for S1 to CCL by POC due date.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022


LIC809 (FAS) - (06/04)
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