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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209320
Report Date: 08/06/2024
Date Signed: 08/06/2024 12:35:37 PM

Document Has Been Signed on 08/06/2024 12:35 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 CAREFACILITY NUMBER:
157209320
ADMINISTRATOR/
DIRECTOR:		STEVEN, CRUZFACILITY TYPE:
735
ADDRESS:2431 CENTER STTELEPHONE:
(415) 810-0145
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY: 22CENSUS: 21DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Administrator Ty SchererTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shawna Doucette and Kamaldeep Kaur arrived at the facility unannounced to conduct a Case Management for a deficiency that was observed during complaint investigations. LPA's identified themselves and discussed the purpose of the visit with Administrator Ty Scherer.

During the course of the investigation of complaint #24-AS-20240502100522, LPA's Mai Yang and Shawna Doucette interviewed Administrator Katie Blair, staff and residents. Refer to above listed complaint for interviews. During the course of the investigation 24-AS-20240509092937, LPA's conducted interviews and reviewed documents. LPA's found an application for BenefitsCal submitted on 01/16/24 for R1. The application was for food stamps and Medi-Cal. LPA reviewed documents and observed Administrator Katie Blair was listed as the Calfresh authorized representative and Staff Brenda Bravo was listed as the authorized person to pick up emergency food from the United States Department of Agriculture The Emergency Food Assistance Program (TEFAP) for R1 dated April 9, 2024.

Refer to complaint 24-AS-20240509092937 for documentation.


An exit interview was conducted with the Administrator and a copy of this report, plan of corrections and appeal rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 08/06/2024 12:35 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Shawna Doucette On 08/06/2024 at 10:38 AM
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
FACILITY NUMBER: 157209320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
08/12/2024
Section Cited
CCR
80068(c)(1)

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80068 Admissions Agreements
(c) Admission agreements must specify the following: (1) Basic services. This requirement was not met as evidenced by. Licensee was not following admissions agreement basic services by
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Plan of Correction Licensee agrees to submit in writing the the understanding of this regulation and provide staff training on facility's duties to residents for basic services by POC due date
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applying for food stamps and emergency for for R1, which poses a potential 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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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