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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 167206283
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:36:52 PM

Document Has Been Signed on 07/29/2024 04:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:EMPLOY AMERICA #3FACILITY NUMBER:
167206283
ADMINISTRATOR/
DIRECTOR:		DONALDSON, NICHOLASFACILITY TYPE:
775
ADDRESS:307 MALL DRIVE STE 105TELEPHONE:
(559) 583-0545
CITY:HANFORDSTATE: CAZIP CODE:
93230
CAPACITY: 60CENSUS: 52DATE:
07/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nicholas Donaldson-Program DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 7/29/24, Licensing Program Analyst’s (LPA’s) J. Leffall and K. Kaur arrived unannounced to conduct an Annual Inspection. LPA’s introduced themselves, stated the purpose of the visit, and met with Program Director (PD) Nicholas Donaldson. Administrator Dawn Reynoso arrived a short time later. All clients were participating in Community Integration during the inspection. LPA’s conducted facility tour with PD.

LPA’s toured the facility. All passageways and exits were clear and free from obstruction. Facility was at comfortable temperature maintained at 70 degrees F. The Day Program has 7 classrooms. LPA’s toured lab room, library, art room, media room, computer club, game room and kitchen. All classrooms and activity areas were clean and odor free. Clients bring their lunches. Kitchen is for small cooking experiences and appeared clean. Food was observed to be stored in refrigerator and freezer. Client’s bathrooms were observed clean, and fixtures were functioning properly. Client lockers were observed in the art room and hall locked. Cleaning supplies observed stored and locked in supply closet. Facility quiet room and changing room was toured. Fire extinguisher observed throughout the facility with a serviced date 11/3/2023. Carbon monoxide was tested and observed to be operational. A sample of client files reviewed to have updated Emergency contacts, Admission agreement, and IPP. 2 out of 5 clients did not have a signed Admission Agreement. 3 out of 5 clients had outdated IPP’s. 3 out of 5 clients were missing Medical Assessments. A sample of staff’s files were also reviewed to have current First Aid/CPR, fingerprinted clear and associated to the facility.

Deficiencies are being cited on the attached 809 in accordance with California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. Plan of Corrections were constructed, reviewed, and provided. The following documents are requested and to be submitted to Fresno CCL by: 8/5/24. LIC 308, LIC 500, LIC 610D, LIC 9283, and LIC 9020. A copy of this report, and appeal rights were provided to Program Director, whose signature confirms receipt of this report.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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 4
Document is an Amendment of Original Document on 01/27/2025 11:51 AM


Created By: Jacques Leffall On 07/29/2024 at 03:23 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: EMPLOY AMERICA #3
FACILITY NUMBER: 167206283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in 2 out of 5 client Admission Agreements were not signed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2024
Plan of Correction
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Administrator to audit all client files to ensure signed Admission Agreements are present, and submit documentation of audit by due date avove.
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/29/2024 04:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 07/29/2024 at 03:49 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: EMPLOY AMERICA #3
FACILITY NUMBER: 167206283

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(a)
80069 Client Medical Assessment (a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in 3 out of 5 client's Medical Assessments, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Administrator to work with client's responsible party to schedule Dr's appointments and submit documentation by due date. Administrator to submit updated Physician's reports when received.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024


LIC809 (FAS) - (06/04)
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