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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 200406214
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:54:40 PM

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:FARR'S FAMILY FACILITYFACILITY NUMBER:
200406214
ADMINISTRATOR:JAIME HERNANDEZ-JOHNSONFACILITY TYPE:
735
ADDRESS:26757 AVENUE 18 1/2TELEPHONE:
(559) 660-5188
CITY:MADERASTATE: CAZIP CODE:
93638
CAPACITY:6CENSUS: 2DATE:
12/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator, Jamie Hernandez-JohnsonTIME COMPLETED:
03:06 PM
NARRATIVE
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On 12/17/2022 Licensing Program Analysts M. Garza and L. Salazar arrived at facility to completed an unannounced Case Management visit. LPA's introduced selves to Administrator. LPA's were granted entry to facility and explained reason for visit. LPA's toured facility inside and out. LPA's completed a Health and Safety check on 2 residents in care. Residents observed in their bedrooms and eating lunch in the dining area. The facility has a total of 6 bedrooms and 4 restrooms.

During the visit LPA's observed a hammer in the hallway cabinet, gardening tools in the backyard and scissors in the craft room. LPA's observed Sister of Administrator, Myrna Soto was not Fingerprint Cleared/Associated (at facility from 12/11/21 through 12/17/21) and removed from facility. LPA's also observed multiple lights without the domes around them and one with an empty light socket.

LPA Garza discussed case management with Administrator. Administrator interviewed for an incident that occurred with R1 on 10/25/2021. Administrator stated that due to R1 going to visit family R1 returns with things all the time that they should not be. Administrator stated the Madera Sheriff came out to speak with R1 at the time and that R1 stated they did not want to injury themselves. Administrator alleged staff is completing room checks once a week on R1. R1's parents also have been spoken to about making sure R1 is not coming home with things they should not be.

Based on observation, interviews, and records review deficiencies have been cited in accordance with the California Code of Regulations, Title 22. See 809D Immediate Civil Penalties assessed.

An exit interview was conducted and Plans of correction were reviewed and developed with Administrator. Appeal rights given
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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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: FARR'S FAMILY FACILITY
FACILITY NUMBER: 200406214
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2021
Section Cited

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80087 Buildings and Grounds
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by: LPA observation of pictures, text sent with SIR, hammer in hall closet, gardening tools in backyard and scissors in craft room.
Type A
12/17/2021
Section Cited

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1522 Fingerprints and criminal records; exemptions; criminal record clearances
The Legislature recognizes the need to generate timely and accurate positive fingerprint identification of applicants as a condition of issuing licenses, permits, or certificates of approval for persons to operate or provide direct care services in a community care facility... (D) Any staff person, volunteer, or employee who has contact with the clients.
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This requirement was not met as evidence by: LPA's observed Sister of Administrator, Myrna Soto was not Fingerprint Cleared/Associated (at facility from 12/11/21 through 12/17/21)
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Facility to pay annual fees by POC date.
Type B
01/15/2022
Section Cited

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1523.1 Fees or taxes on licenses or special permits; exemptions; use of revenues collected; denial or forfeiture (e) The failure of an applicant or licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidence by CCL documentation reflects $681.00 past due.
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: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021
LIC809 (FAS) - (06/04)
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