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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209003
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:51:13 PM

Document Has Been Signed on 08/12/2024 04:51 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:KOOTENAY COURTFACILITY NUMBER:
157209003
ADMINISTRATOR/
DIRECTOR:		CUA, ROSALINDAFACILITY TYPE:
735
ADDRESS:2808 KOOTENAY COURTTELEPHONE:
(661) 412-8548
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 4CENSUS: 4DATE:
08/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:Shellie Ryan, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On 8/12/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Case Management visit. LPA arrived, introduced self, and allowed entrance by Direct Care Staff. Administrator contacted by telephone and not available for in person visit but available by telephone. Facility manager arrived a short time later to conduct visit with LPA.

On 7/15/2024, this department received an age exception request for R1, however R1 was placed in facility prior to department approval, which is a violation of Title 22 regulations. Administrator acknowledged not being familiar with regulation in regards to age requirements.

Deficiencies cited on the attached 809D

Exit interview conducted. A copy of this report provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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 08/12/2024 04:51 PM - It Cannot Be Edited


Created By: Melinda Medina On 08/12/2024 at 04:02 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: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2024
Section Cited
CCR
80010(a)

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A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.
**This was not met as evidenced by licensee admitted R1 who was under the age of 18 without prior age exception approval from department.
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Licensee submitted age exception request for R1 on 7/15/24.


DEFICIENCY CLEARED AT TIME OF VISIT
Type A
08/13/2024
Section Cited
CCR
80064(a)(3)

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a) The administrator shall have the following qualifications: (3) (3) Knowledge of and ability to comply with applicable law and regulation. ***This was not met as evidenced by facility accepted client under the age of 18 which is not in compliance with Title 22 regulation.
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Licensee to submit written plan as to how to remain in compliance with Title 22 regulation.

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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:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024


LIC809 (FAS) - (06/04)
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