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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209085
Report Date: 09/19/2022
Date Signed: 09/19/2022 04:02:26 PM

Document Has Been Signed on 09/19/2022 04:02 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:MARIGOLD PALS HOUSEFACILITY NUMBER:
157209085
ADMINISTRATOR:HOUCK, HELEN S.FACILITY TYPE:
735
ADDRESS:212 HAGGIN STREETTELEPHONE:
(661) 742-1088
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Helen Houck, LicenseeTIME COMPLETED:
02:30 PM
NARRATIVE
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On 9/19/22 at 12:15 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator Helen Houck arrived a short time later.

LPA toured inside and outside of facility. 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. Hand washing posters were observed by sinks. Residents each have a private room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Bulk of PPE supplies are kept at a separate facility. Residents files have updated emergency contact information. Administrator certification is current.

The following deficiency was observed:
1. S1 is not associated to the facility and has been working since 4/1/22.

The following forms are to be submitted to CCL within 2 weeks:
LIC610D, LIC500, LIC400, LIC402

A deficiency is being cited based on LPA interview, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.

An exit interview was conducted. A copy of this report and appeal rights were given to Licensee Helen Houck, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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 09/19/2022 04:02 PM - It Cannot Be Edited


Created By: Malia Thao On 09/19/2022 at 01:21 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: MARIGOLD PALS HOUSE
FACILITY NUMBER: 157209085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(2)
(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: (2) 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
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Based on interview and record review, the licensee did not comply with the section cited above. S1 is not associated to the facility and has been working since 4/1/22, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2022
Plan of Correction
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Licensee associated S1 to the facility via Guardian during the inspection. POC cleared during the inspection.
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: 09/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2022


LIC809 (FAS) - (06/04)
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