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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209066
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:22:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2022 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220602144408
FACILITY NAME:PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACEFACILITY NUMBER:
157209066
ADMINISTRATOR:VICKERS, TYSON W.FACILITY TYPE:
735
ADDRESS:809 WELLMAN WAYTELEPHONE:
(661) 412-4541
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 5DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Licensee, Tyson Vickers and Administrator Adonica VickersTIME COMPLETED:
02:31 PM
ALLEGATION(S):
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Staff are mismanaging client medications
INVESTIGATION FINDINGS:
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On 06/07/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Complaint Investigation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff, Megan Cadena granted LPA entry to the facility and contacted the Administrator via telephone. Licensee, Tyson Vickers and Administrator, Adonica Vickers arrived a short time later.

During today's inspection, LPA reviewed records, interviewed staff and residents, and conducted a facility tour.

Based on review of records and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation: Staff are mismanaging client medications is found to be SUBSTANTIATED. CONTINUED TO LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 24-AS-20220602144408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACE
FACILITY NUMBER: 157209066
VISIT DATE: 06/07/2022
NARRATIVE
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A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 9099D.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with Licensee and Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Adonica Vickers, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2022 and conducted by Evaluator Alexandria Walton
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220602144408

FACILITY NAME:PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACEFACILITY NUMBER:
157209066
ADMINISTRATOR:VICKERS, TYSON W.FACILITY TYPE:
735
ADDRESS:809 WELLMAN WAYTELEPHONE:
(661) 412-4541
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 5DATE:
06/07/2022
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Licensee, Tyson Vickers and Administrator Adonica VickersTIME COMPLETED:
02:31 PM
ALLEGATION(S):
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Facility is not providing client essentials per admission agreement
Facility does not provide adequate milk and juice to meet client needs
INVESTIGATION FINDINGS:
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On 06/07/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Complaint Investigation. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff, Megan Cadena granted LPA entry to the facility and contacted the Administrator via telephone. Licensee, Tyson Vickers and Administrator, Adonica Vickers arrived a short time later.

During today's inspection, LPA reviewed records, interviewed staff and residents, and conducted a facility tour. Based on facility tour, record review, and interviews conducted, the allegations: Facility is not providing client essentials per admission agreement and Facility does not provide adequate milk and juice to meet client needs are UNSUBSTANTIATED.

CONTINUED TO 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20220602144408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACE
FACILITY NUMBER: 157209066
VISIT DATE: 06/07/2022
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies issued during today's inspection.

Exit interview conducted with Licensee and Administrator. A copy of this report was discussed and provided to Administrator, Adonica Vickers, whose signature on this form confirms receiving this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20220602144408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PURPOSEFUL RESIDENTIAL CARE: WELLMAN PLACE
FACILITY NUMBER: 157209066
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2022
Section Cited
CCR
80075(b)
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80075 Health Related Services (b): (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 80075(b) are met to the Fresno CCL office by the POC due date.
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Based on interviews and record review, the faciltiy did not ensure all residents were assisted with self-administration of prescription medications. This poses an immediate health and safety risk to residents in care.
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Licensee agreed that staff will be trained on the requirements of Health Related Services. Documentation of training topics and attendance will be submitted to the Fresno CCL office by 07/08/2022
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5