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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209320
Report Date: 08/05/2023
Date Signed: 08/05/2023 11:14:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/01/2023 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20230801114417
FACILITY NAME:CENTER STREET BOARD AND CAREFACILITY NUMBER:
157209320
ADMINISTRATOR:BARBATO, ANTHONY M.FACILITY TYPE:
735
ADDRESS:2431 CENTER STTELEPHONE:
(415) 810-0145
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:22CENSUS: 19DATE:
08/05/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Administrator Steven CruzTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not administer medication to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted a visit to commence a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Steven Cruz.

LPA reviewed records and interviewed staff. Staff did not have a start date for medication and verbally stated C1's medication started on 08/2/23. C1's medication shows given already for today and was not supposed to be administered until bedtime. LPA took photos of medication.

Based on record review and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted with Administrator Steven Cruz and a copy of this report along with appeal rights and plan of correction were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 24-AS-20230801114417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 157209320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2023
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 was not met as evidenced by: The Licensee did not have a start date for medication and stated
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Plan of Correction POC Licensee agrees to conduct medication training by POC due date 08/11/23 providing an agenda and sign in sheet.
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medication started on 8/2/23, which showed C1 was already given his bedtime medication for 8/5/23. This poses an immediate health safety and/or personal rights 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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5