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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209085
Report Date: 09/17/2025
Date Signed: 09/17/2025 01:52:57 PM

Document Has Been Signed on 09/17/2025 01:52 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:MARIGOLD PALS HOUSEFACILITY NUMBER:
157209085
ADMINISTRATOR/
DIRECTOR:		HOUCK, HELEN S.FACILITY TYPE:
735
ADDRESS:212 HAGGIN STREETTELEPHONE:
(661) 742-1088
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 5CENSUS: 4DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Claudia Yvonne RamirezTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 09/17/25, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to conduct the required Annual inspection. LPA introduced self, stated the purpose of the visit, and met with staff Gey Ler. Staff contacted Administrator (AD) Claudia Yvonne Ramirez and she arrived shortly after. LPA toured the facility with AD. LPA observed one resident in the living room watching TV. Staff stated that the other residents were at day program and/or at doctor appointments.

The facility was observed to be at a temperature of 78 degrees F, clean, in good repair, and no passageway obstructions were observed. The living room has sufficient seating for residents. Living room has a fireplace with a cover. The kitchen was toured and LPA observed an adequate supply of perishable and non-perishable food. The facility stores kitchen knives in a locked kitchen cabinet. Chemicals were observed locked in a kitchen cabinet.

All bedrooms were toured and observed to have the required furniture and adequate lighting. Bathrooms were observed operational. The hallway restroom hot water measured at 108.7 degrees F and the hot water in the restroom to bedroom number one measured at 110.5 degrees F. Extra linens and towels were observed stored in a hall closet.

LPA toured the garage. The facility has a dryer and washer in the garage and detergent locked in a cabinet. The facility has an additional freezer in the garage with an additional food supply. Outside of the facility toured and observed to be free of debris with adequate seating available for residents under a gazebo.

The carbon monoxide/smoke detectors were observed operational during inspection. Medications observed kept locked in facility office. Medications were reviewed along with MARS and observed to be administered as prescribed. A first aid kit is also stored in the office. All resident files and a sample of staff files were reviewed and observed to have required documentation.

Continued in LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Serigy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Jimmy Duarte
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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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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)
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Document Has Been Signed on 09/17/2025 01:52 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 09/17/2025 at 12:54 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: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80077.3(a)
Care for Clients who Lack Hazard Awareness or Impluse Control
(a) If a client requires protective supervision because of running/wandering away, supervision may be enhanced by fencing yards, using self-closing latches and gates, and installing operational bells, buzzers, or other auditory devices on exterior doors to alert staff when the door is opened. The fencing and devices must not substitute for appropriate staffing.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observaton, the licensee did not comply with the section cited above in that LPA observed the gate in the backyard has a deadbolt and a slide gate latch at the bottom of the door that secures the gate from opening.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Licensee agrees to remove the slide gate latch that is at the bottom of the door that ecures the door from opening and will provide pictures to show latch was removed by POC due date of 09/24/24.
Type A
Section Cited
CCR
80075(b)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (2) Facility staff, except those authorized by law, shall not administer injections but staff designated by the licensee shall be authorized to assist clients with self-administration of injections as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that S1 stated that S1 and other staff administer injection medication for R1,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2025
Plan of Correction
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Licensee agrees to train staff on administration of medication. Licensee will schedule training, indicate training topics that were discussed and provide a list of staff who attended training by POC due date of 09/24/25.
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: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/17/2025 01:52 PM - It Cannot Be Edited


Created By: Jimmy Duarte On 09/17/2025 at 12:54 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: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.2(a)
Restricted Health Condition Care Plan
(a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. The plan must include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in that R1 has a restricted health condition and facility does not have a restricted health condition care plan for R1, which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 09/24/2025
Plan of Correction
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Licensee agrees to develop and maintain a restricted health condition care plan and provide LPA a copy by POC due date of 09/24/25.
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.
Serigy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:
Jimmy Duarte
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


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: MARIGOLD PALS HOUSE
FACILITY NUMBER: 157209085
VISIT DATE: 09/17/2025
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Continued from LIC 809.

A fire extinguisher was observed in the sitting room with a service date of 05/15/25. Per staff records, the last fire drill was conducted on 08/28/25.

LPA observed the gate in the backyard has a deadbolt and a slide gate latch at the bottom of the door that secures the gate from opening.



R1 has a restricted health condition; however, facility did not have a restricted health condition care plan for R1. In addition, per interview with S1, S1 and other staff administers injectable medication for R1.

A deficiency is being cited on the attached LIC 809D in accordance to California Code of Regulations, Title 22,Division 6.

An exit Interview was conducted. A copy of this report and appeal rights were provided to AD, whose signature on this form confirms receipt of this report.

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

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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