<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209319
Report Date: 07/17/2024
Date Signed: 07/17/2024 07:34:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/17/2024 07:34 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:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:01 PM
MET WITH:Administrator Steven CruzTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Shawna Doucette and Kamaldeep Kaur arrived at the facility to conduct an annual inspection. LPA's met with Administrator Steven Cruz.

LPA's had a replication error and lost an 809d page. LPA's will address the medication errors on this case management.

Refer to 809d and civil penalty issued.

A copy of this report was provided with appeal rights and plan of corrections.
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)
Page: 1 of 2
Document Has Been Signed on 07/17/2024 07:34 PM - It Cannot Be Edited


Created By: Shawna Doucette On 07/17/2024 at 07:04 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7

80075 (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by Licensee did not
1
2
3
4
5
6
7
Plan of Correction Licensee agrees to conduct a medication training by POC due date 7/30/24.
8
9
10
11
12
13
14
ensure R2 received her morning medication until 12 PM and R4 did not have medication on 7/14/24, 07/15/24 and 7/16/24 which poses an immediate health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
Request Denied
Type A
07/30/2024
Section Cited
CCR80075(k)(4)

1
2
3
4
5
6
7

80075 (k) The following requirements shall apply to medications which are centrally stored: (4) No person other than the dispensing pharmacist shall alter a prescription label. This requirement was
1
2
3
4
5
6
7
Plan of Corrention Licensee agrees to conduct a training to meet this regulation by POC due date 07/30/24.
8
9
10
11
12
13
14
not met as evidenced by Licensee used black marker to cross out the prescription label advising to administer in the morning and hand wrote in administer at 12 pm which poses and immediate health safety and or personal rights risk to residents in care.
8
9
10
11
12
13
14
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)
Page: 2 of 2