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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209191
Report Date: 04/28/2023
Date Signed: 04/28/2023 06:58:18 PM


Document Has Been Signed on 04/28/2023 06:58 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:WESTCHESTER HOME ON SPRUCE, THEFACILITY NUMBER:
157209191
ADMINISTRATOR:KAUR, LAKHWINDERFACILITY TYPE:
740
ADDRESS:2485 SPRUCE STREETTELEPHONE:
(661) 633-1225
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93301
CAPACITY:6CENSUS: 4DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Manjit Chauhan and Lakhwinder Kaur, LicenseesTIME COMPLETED:
07:20 PM
NARRATIVE
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On 4/28/23 at 12:25 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensees (LIC) Manjit Chauhan and Lakhwinder Kaur arrived a short time later.

LPA toured the facility with LIC Manjit. Facility set at comfortable temperature. All bedrooms were sufficiently furnished and lighted. Bathrooms observed with grab bars for each toilet and shower, non-skid mats, hand soap, paper towels, and hand washing signs. Smoke and carbon monoxide combo detector tested and operational. 2-day perishables and 7-day non-perishables supply of food observed. Sample of staff and resident records reviewed.

The following deficiencies were observed:
1. Two paint cans were observed accessible in the unlocked first hall bathroom cabinet.
2. S3 has been working in the facility since 4/22/22, was present in the facility during inspection, and does not have a completed request for transfer of criminal record clearance.
3. S1 has been working in the facility since 3/27/23, was present during the inspection, and does not have a completed request for transfer of criminal record exemption.

Deficiencies are being cited based on LPA observations, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days for S1 and S3, for a total of $1000. See both LIC421BG for more details. Due to time constraints, an Annual Continuation will be conducted. Exit interview conducted. A copy of this report and appeal rights were given to Licensee Manjit Chauhan, whose signature confirms receipt of this report. Plan of Corrections was reviewed and developed with Licensee.

The following updated forms are to be submitted within two weeks: LIC610E, LIC9020A, LIC500, LIC308

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 04/28/2023 06:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WESTCHESTER HOME ON SPRUCE, THE
FACILITY NUMBER: 157209191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed two paint cans accessible in the unlocked first hall bathroom cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Licensee immediately removed the two paint cans to the locked garage unit. POC cleared during inspection.
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. S3 has been working in the facility since 4/22/22, was present in the facility during inspection, and does not have a completed request for transfer of criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Licensee completed the LIC9182 form and LPA was able to complete the transfer of criminal record clearance of S3 on the Guardian website. POC cleared during the inspection.
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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 04/28/2023 06:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: WESTCHESTER HOME ON SPRUCE, THE
FACILITY NUMBER: 157209191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. S1 has been working in the facility since 3/27/23, was present during the inspection, and does not have a completed request for transfer of criminal record exemption, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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S1 left the facility during the inspection. Licensee provided a written statement that Licensee will ensure completion of a request for transfer of criminal record exemption for S1 by verifying with CPMB, the Fresno Regional Office, or LPA and stating that S1 will not be working until verification is made. POC cleared during inspection.
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.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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