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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 03/13/2024
Date Signed: 03/22/2024 10:05:07 AM


Document Has Been Signed on 03/22/2024 10:05 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
FRESNO ASC, 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:
03/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility staff Lacy VincentTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analysts (LPA's) Sarah Hurt and Brianna Miranda conducted a Case Management visit. LPA met with facility Facility staff Lacy Vincent, and explained the purpose of today's visit. Licensee Jessica Johnson was not present at the facility during this visit, but did contact LPA Hurt via phone.


LPA's requested a current facility resident roster. LPA's requested the current Needs and Services Plan, and Physician's Report (LIC602) for all current facility residents.

Staff 1 has not been associated to the current facility.
Staff 2 is not background/fingerprint cleared.

Exit interview conducted with facility staff Lacy Vincent, and a copy of this report provided.


SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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 2


Document Has Been Signed on 03/22/2024 10:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: ATWATER RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 247209209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2024
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
The following requirement has not been met as evidenced by:
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Licensee will submit LIC 9182 form to associate Staff 1 to the facility, and send proof to LPA by POC date of 03/14/2024.
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Staff 1 is not associated to this facility in LIS or guardian, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
03/14/2024
Section Cited
CCR87355(b)

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87355 Criminal Record Clearance

(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
The following requirement has not been met as evidenced by:
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Licensee will remove staff 2 from the facility, and staff will no longer provide care to facility residents until cleared and associated to the facility.
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Staff 2 is not background cleared and has been providing care to residents for one month, which poses an immediate, health, safety, 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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2