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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209319
Report Date: 07/17/2024
Date Signed: 07/18/2024 12:27:33 PM

Document Has Been Signed on 07/18/2024 12:27 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:CENTER STREET BOARD AND CARE 2FACILITY NUMBER:
157209319
ADMINISTRATOR/
DIRECTOR:
CRUZ, STEVENFACILITY TYPE:
735
ADDRESS:2451 CENTER STTELEPHONE:
(415) 810-0145
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 18CENSUS: 18DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Administrator Steven Cruz and Staff Ty SchererTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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LPA Shawna Doucette and Kamaldeep Kaur arrived at the facility unannounced to conduct an annual inspection. LPA was granted entry by Staff Sue Devilbiss. LPA explained the purpose of the visit and met with Regional Director Steven Cruz and Staff Ty Scherer.

A tour of the facility was conducted with Staff Ty Scherer. The facility was set at 75 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked medication cart in office/medication room. Cleaning supplies were in a locked storage closet. Smoke detectors and carbon monoxide detectors were checked and operating. Facility had a pull station fire alarm. Facility has a fire sprinkler system. Fire extinguishers were charged and had service dates of 05/13/24. LPA checked water temperature in resident bathroom which was 117.5 F. Resident bathroom had a rusted bathtub and rusted sink. The other resident bathroom had black mold and the flooring is damaged. LPA took photos.

There was outdoor seating for the residents.

Resident, medication and staff records were reviewed. While reviewing records, LPA observed R2 receiving morning medication at noon and R4 not receiving medication on 7/14/24, 07/15/24 and 07/16/24. Facility crossed out original label stating to administer in the morning with a black marker and wrote in 12 PM. Facility did not have doctor orders for R1's restricted health care plan, showing when blood sugar tests should be completed and a doctor order for sliding scale as to how much medication is to be administered depending on blood sugar test. LPA took photos of medication errors. R1 did not have a needs and service plan. Training has dates and hours with names of staff but does not state the source of where the training.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
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 07/18/2024 12:31 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/17/2024 06:55 PM


Created By: Shawna Doucette On 07/17/2024 at 03:51 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CENTER STREET BOARD AND CARE 2

FACILITY NUMBER: 157209319

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not keep residents bathrooms free from mold and rust in sink and bathtub and mold in shower and damaged flooring which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee agrees to fix the bathroom sink, bathtub, shower and flooring in the residents bathroom. Licensee agrees to remove the mold from the other resident bathroom by POC due date 8/14/24. LPA took photos.
Section Cited
Fixtures, Furniture, Equipment, and Supplies
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
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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Document Has Been Signed on 07/17/2024 06:43 PM - It Cannot Be Edited


Created By: Shawna Doucette On 07/17/2024 at 03:51 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: CENTER STREET BOARD AND CARE 2

FACILITY NUMBER: 157209319

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have a needs and service plan for R1 who has a restricted health condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee agrees to submit a needs and service plan for R1 by POC due date 7/26/24.
Deficiency Dismissed
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have completed staff training, training does not state who conducted trainings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee agrees to submit example of staff training that will meet the requirements and provide a copy of the training in the staff personnel files by POC due date 8/16/24.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
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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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: CENTER STREET BOARD AND CARE 2
FACILITY NUMBER: 157209319
VISIT DATE: 07/17/2024
NARRATIVE
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material was obtained. Current first aid and CPR were reviewed.

Refer to 809d for deficiencies. Civil Penalty issued for repeat violation.

A copy of this report was provided to Administrator with plan of corrections and appeal rights.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
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
LIC809 (FAS) - (06/04)
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