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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209184
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:48:44 PM

Document Has Been Signed on 01/27/2023 12:48 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:THOMAS, TATIANNAFACILITY TYPE:
737
ADDRESS:2700 PACINI STREETTELEPHONE:
(661) 589-9992
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 3CENSUS: 2DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Operations Manager, Alexis Rutledge, Social Worker, Isaac Gomez and Administrator, Miranda WrightTIME COMPLETED:
01:03 PM
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On 01/27/2023, 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. Facility staff contacted Administrator, Tatianna Thomas. Administrator was unable to attend this visit, LPA met with Operations Manager, Alexis Rutledge, Social Worker, Isaac Gomez and Administrator, Miranda Wright.

The purpose of this visit is to follow up on an incident that was reported to the Fresno CCL Office. It was reported that on 12/02/2022, an unknown staff misplaced medication for R1. R1 did not receive the medication as prescribed on 12/02/2022, 12/03/2022 and 12/04/2022.

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

Exit interview conducted and a plan of correction was reviewed and developed with Operation. A copy of this report and appeal rights were provided to Operations Manager, 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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 01/27/2023 12:48 PM - It Cannot Be Edited


Created By: Alexandria Walton On 01/27/2023 at 12:00 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: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2023
Section Cited
CCR
80075(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 agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 80075 are met to the Fresno CCL office by the POC due date.
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Based on record review, the licensee did not ensure the requirements for this section were met when an unknown staff misplaced R1's medication, resulting in R1 missing the medication for 3 days which is an immediate health and safety risk 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023


LIC809 (FAS) - (06/04)
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