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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 06/30/2022
Date Signed: 06/30/2022 10:40:52 AM


Document Has Been Signed on 06/30/2022 10:40 AM - 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:ATWATER RESIDENTIAL CARE FACILITYFACILITY NUMBER:
247209209
ADMINISTRATOR:JOHNSON, JESSICAFACILITY TYPE:
740
ADDRESS:1691 JOE SILVA AVENUETELEPHONE:
(209) 430-1688
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:5CENSUS: 4DATE:
06/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Caregiver, Angely SolteroTIME COMPLETED:
10:50 AM
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On 06/30/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Plan of Correction (POC) inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Denise Ordoniez via telephone. LPA waited for approximately 1 hour for Administrator to arrive. Administrator did not arrive during the inspection, LPA met with Caregiver, Angely Soltero.

On 06/17/2022, LPA conducted a Post-Licensing inspection at the above facility. LPA issued a citation based on California Code of Regulations section 87465 (a)(4): Licensee shall assist residents with self-administered medications. Licensee did not have 2 medications prescriptions filled in the facility that were listed on the MAR for R2 and did not administer 8 days of medications for R1. LPA and Administrator, Jessica Johnson developed a plan of correction where Licensee agreed to submit a written statement detailing the facility’s plan to meet the requirements of section 87465 by 06/20/2022.

As of today, Licensee has not submitted the plan of correction to the Fresno CCL office.

A civil penalty is being assessed in the amount of $100 per day until the plan of correction is submitted to the Fresno CCL office.

Exit interview conducted. A copy of this report and appeal rights were discussed and provided to Caregiver, Angely Soltero, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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