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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209184
Report Date: 06/19/2023
Date Signed: 06/19/2023 01:01:13 PM

Document Has Been Signed on 06/19/2023 01:01 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:AIMES PACINIFACILITY NUMBER:
157209184
ADMINISTRATOR:RUTLEDGE, ALEXISFACILITY TYPE:
737
ADDRESS:2700 PACINI STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 3CENSUS: 3DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Administrator, Sean Battle and Administrator, Alexis RutledgeTIME COMPLETED:
01:23 PM
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On 06/19/2023, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct a case management inspection. LPA introduced self and stated the purpose of the visit and was allowed to enter the facility. LPA met with Administrators, Alexis Rutledge and Sean Battle.

The purpose of today's visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 04/27/2023, S1 assaulted R1 in an attempt to de-escalate an incident. S1's employment was terminated.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. An immediate civil penalty is being assessed in the amount of $500, see LIC421IM.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report, civil penalty and appeal rights were discussed and provided to the Administrator, whose signature on this form confirms receipts of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2023
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 06/19/2023 01:01 PM - It Cannot Be Edited


Created By: Alexandria Walton On 06/19/2023 at 12:39 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: AIMES PACINI
FACILITY NUMBER: 157209184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2023
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights:(a)...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature... This requirement was not met as evidenced by:
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Licensee terminated the employment of S1. POC cleared during the inspection.
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Based on record review, the Liscensee did not ensure the requirements for section 80072(a)(3) were met when S1 assaulted R1 in an attempt to de-escalate an incident, which posses an immediate health and safety check to residents in care.
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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:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023


LIC809 (FAS) - (06/04)
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