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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209184
Report Date: 07/17/2024
Date Signed: 07/17/2024 01:02:45 PM

Document Has Been Signed on 07/17/2024 01:02 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:AIMES PACINIFACILITY NUMBER:
157209184
ADMINISTRATOR/
DIRECTOR:		RUTLEDGE, ALEXISFACILITY TYPE:
737
ADDRESS:2700 PACINI STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 3CENSUS: 3DATE:
07/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:19 PM
MET WITH:Administrator, Alexis RutledgeTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 07/17/2024, Licensing Program Analyst (LPAs) Walton and Leffall arrived unannounced to conduct a case management inspection. LPAs introduced themselves, stated purpose of the visit, and requested to meet with the Administrator. LPAs met with Administrator, Alexis Rutledge.

The purpose of this visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 06/28/2024, facility staff placed R1's medication in a medication cup. R1 received the medication cup, took the medication, and placed the medication cup on the top of the refrigerator. On 06/29/2024, facility staff discovered the medication Simvastatin 10mg stuck to the bottom of the medication cup. Record review and interviews confirmed that R1 missed the 06/28/2024 evening medication Simvastatin.

A deficiency is being issued in accordance to California Code of Regulation, Title 22, Division 6 on the attached 808D.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Alexis Rutledge, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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 07/17/2024 01:02 PM - It Cannot Be Edited


Created By: Alexandria Walton On 07/17/2024 at 12:34 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: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2024
Section Cited
CCR
80075(b)

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80075 Health Related Services: (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 began utilizing clear medication cups and all staff received medication training. POC cleared.
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Based on record review and interviews, the licensee did not ensure that all cleints were assisted as needed with medications when R1 missed an evening medication, which poses an immediate health and safety risk to clients 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: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
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