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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209003
Report Date: 10/28/2025
Date Signed: 10/28/2025 03:55:45 PM

Document Has Been Signed on 10/28/2025 03:55 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KOOTENAY COURTFACILITY NUMBER:
157209003
ADMINISTRATOR/
DIRECTOR:		CUA, ROSALINDAFACILITY TYPE:
735
ADDRESS:2808 KOOTENAY COURTTELEPHONE:
(661) 412-8548
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 3DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Ronald DuranTIME VISIT/
INSPECTION COMPLETED:
04:30 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
On 10/28/2025, Licensing Program Analyst (LPA) J. Duarte arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Supervisor, Maria Torrealba. The supervisor contacted Administrator, Ronald Duran. LPA conducted a tour with the supervisor Maria and Ronald arrived shortly after. The supervisor reported that there are four residents, three were at home, and one resident was at day program.

The facility was observed to be at a temperature of 70 degrees F. There were no passageway obstructions or fire hazards. All common areas were properly furnished and well lit. LPA observed a seven day supply of non-perishable food and a two day supply of perishable food. The sharps are kept secured in a locked kitchen cabinet. Medication is also stored in a locked kitchen cabinet. In addition, chemicals and detergent are stored in a locked kitchen cabinet.

LPA toured the resident bedrooms and all bedrooms were observed to be adequately furnished. LPA tested the water temperature in the hallway and it measured at 107.6 degrees F. The hot water to main bedroom that has a restroom measured at 108.5 degrees F.

The garage was toured and LPA observed a washer and dryer. The supervisor stated that they do their own laundry. Extra bedding and linen are stored in a hallway closet.

Continued on LIC 809-C.
NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document is an Amendment of Original Document on 10/30/2025 09:09 AM


Created By: Jimmy Duarte On 10/28/2025 at 01:24 PM
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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: KOOTENAY COURT
FACILITY NUMBER: 157209003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that staff reported that that C1 AWOLs and lock mechanisms where put in place to secure the fence from opening and to slow down C1 from leaving. LPA observed both side gates to have latches on the top and bottom of the gate that are secured from the front side of the yard, making the gate inaccessible to open from the backyard side and preventing anyone to come out to the front yard.

In addition, LPA observed the fire extinguisher was last serviced on 10/23/24.which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 10/29/2025
Plan of Correction
1
2
3
4
Licensee removed latches from both side gates and exchanged the fire extinguisher with a fire extinguisher that has a receipt with date of of purchase of 5/31/25, while LPA was at the facility.
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, intereview, and record review, the licensee did not comply with the section cited above in that S1, S5, and S6 were cleared to work at another facility; however, a transfer was not requested and they were not associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.

S1 and S2 stated that S1 has been employed since 09/18/25 and has only worked at this facility. However, S1 was cleared to work at another facility and is not associated to this facility.
S3 stated that S1 works at another facility and S1 was filling in for another staff today.
In addition, S5 and S6 arrived for the PM shift. Initally S3 stated that he associated S5 on 10/01/2025 and associated S6 in the moment LPA was completing inspection. However, S3 then stated that both S5 and S6 were associated on this day, while LPA was completing this annual inspection.
POC Due Date: 10/29/2025
Plan of Correction
1
2
3
4
Licensee associated S1, S5, and S6 to the facility, while LPA was at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/28/2025 03:55 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 10/28/2025 at 01:24 PM
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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that the carpet in the resident rooms is stained. The licensee stated that he noticed the carpet was stained approximately two weeks ago and stated that he will be replacing the carpet. In addition, both side gates of the facility had two wood planks that are broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
1
2
3
4
Licensee stated that he will replace the carpet in the resident rooms and will replace the broken wooden planks to the side gates. Licensee will provide proof to CCL by POC due date of 11/28/2025.
Type B
Section Cited
CCR
80068.3(a)
Modifications to Needs and Services Plan
(a) The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in that two out of four residents IPPs were over one year old, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
1
2
3
4
Licensee stated IPPs will be requested from Kern Regional Center and will provide proof of request to CCL by POC due date of 11/07/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: KOOTENAY COURT
FACILITY NUMBER: 157209003
VISIT DATE: 10/28/2025
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
26
27
28
29
30
31
32
Continued from LIC809.

LPA reviewed medication and MARS and logs reflect medications are being administered as prescribed. Staff records were reviewed for good health and training.

A fire extinguisher was observed in the living room with a service date of 10/23/24. Smoke Alarm and Carbon Monoxide detectors were tested and observed operational during visit. Per staff records, the last fire drill was conducted on 10/15/25..

LPA observed stained carpet in resident rooms. In addition, both side gates of the facility had a broken wood plank.

LPA reviewed client records and two out of four residents IPPs were over one year old.

LPA observed both side gates to have latches on the top and bottom of the gate that are secured from the front side of the yard, making the gate inaccessible to open from the backyard side and preventing anyone to come out to the front yard. In addition, LPA observed the fire extinguisher was last serviced on 10/23/24

Staff files were reviewed and LPA observed S1 was cleared to work at another facility; however, a transfer was not requested for S1 and S1 was not associated to this facility. In addition, afternoon staff arrived and S5 and S6 were not associated to the facility. Administrator, Ronald Duran, associated all staff while LPA was at the visit.

Deficiencies cited per California Code of Regulations, Title 22, Division 6, Chapter 8, on the attached 809D. If not corrected, the violation will have a direct and immediate risk to the health safety and or personal rights of persons in care. ***Civil penalties are being assessed for criminal record transfer and for fire clearance.***

Exit interview was conducted with Administrator, Ronald Duran. A copy of this report, deficiencies, civil penalties and appeal rights were discussed and provided to Administrator.

LPA requested the following updated forms be faxed to CCL Department: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage by 10/29/25 and POCs to be submitted by POC due date.

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5