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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209054
Report Date: 05/02/2022
Date Signed: 05/02/2022 11:45:23 AM

Document Has Been Signed on 05/02/2022 11:45 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:WILLY HOMEFACILITY NUMBER:
157209054
ADMINISTRATOR:GO, CELESTEFACILITY TYPE:
734
ADDRESS:3702 ABBEY ROADTELEPHONE:
(661) 843-7739
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 5DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stacyrae Seares, AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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On 5/2/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. Administrator Stacyrae Seares arrived a short time later. Five staff and five residents were present during the inspection.

A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one entrance/exit point for visitors and a separate entry point for residents/staff. Facility was observed clean and without any obstructions. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. All hoyer lifts observed operational. LPA observed med cart and excess supply of meds. Food supply observed sufficient. Cleaning and PPE supplies were observed sufficient. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is expired as of 3/29/22, but has an application for recertification pending.

The following updated forms are to be submitted to CCL within 2 weeks:
LIC500, LIC400, LIC402, LIC610D (new revision)

The following deficiencies were cited:

1. Hot water in west bathroom measured at 125.3 degrees F.

Deficiencies is being cited based on LPA observation conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.



Exit interview conducted. A copy of this report and appeal rights were given to Administrator Stacyrae Seares, whose signature confirms receipt of this report.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
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 05/02/2022 11:45 AM - It Cannot Be Edited


Created By: Malia Thao On 05/02/2022 at 11:17 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: WILLY HOME
FACILITY NUMBER: 157209054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water in west bathroom measured at 125.3 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2022
Plan of Correction
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Administrator will submit proof of hot water in west bathroom measuring within range of 105-120 degrees F 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022


LIC809 (FAS) - (06/04)
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