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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209184
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:22:42 PM

Document Has Been Signed on 09/19/2023 12:22 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:BATTLE, SEANFACILITY TYPE:
737
ADDRESS:2700 PACINI STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 3CENSUS: 3DATE:
09/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Administrator, Alexis RutledgeTIME COMPLETED:
12:31 PM
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On 09/19/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Alexis Rutledge.

The purpose of this visit is to follow up on an incidents that occurred at the above facility on 08/07/2023 and 08/18/2023.

The facility reported that on 08/07/2023 at approximately 4:00PM, facility staff did not asisst C3 with self-administration of a prescribed medication. Per Administrator, facility staff did not administer the 400mg Acyclovir during the 4:00PM medication pass to C3 resulting in C3 missing the medication.

The facility reported that on 08/18/2023 at approximately 2:48AM, C1 entered C2's room and put genitals in C2's face. Facility staff failed to provide 1:1 supervision to C1 and C2 as evidenced by staff not intervening to stop the incident from occurring.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. A civil penalty in the amount of $250 is being assessed for repeat violation.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights were discussed and provided to Administrator, Alexis Rutledge, via email due to technical issues. Report was signed on site by Administrator.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 09/19/2023 12:22 PM - It Cannot Be Edited


Created By: Alexandria Walton On 09/19/2023 at 11:41 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: AIMES PACINI
FACILITY NUMBER: 157209184

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
80078(a)

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80078: (a) The licensee shall provide care and supervision as necessary to meet the client's needs... This requirment was not met as evidenced by:
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Licensee agreed to submit a written statement detailing the steps the facility will take to ensure that clients in care are provided care and supervision necessary to meet their needs to the Fresno CCL office by the POC due date.
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Based on record review and interviews when on 08/18/2023 at approximately 2:48AM, C1 entered C2's room and put genitals in C2's face. Facility staff failed to provide 1:1 supervision to C1 and C2 as evidenced by staff not intervening to stop the incident from occurring.
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Type A
09/20/2023
Section Cited
CCR80075(b)

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(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 agreed 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 record review, the licensee did not comply with the section 80075(b) when facility staff did not asisst C3 with self-administration of a prescribed medication.
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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: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
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