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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209209
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:38:05 PM


Document Has Been Signed on 07/13/2022 12:38 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: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: 2DATE:
07/13/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Administrator, Jessica JohnsonTIME COMPLETED:
01:30 PM
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On 07/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a POC visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator via telephone. LPA met with Administrator, Jessica Johnson, who arrived a short time later.

LPA amended a report that was created on 06/17/2022.

On 06/17/2022, the above facility received a citation based on California Code of Regulations section 87465 (a)(4): Licensee shall assist residents with self - administered medications. 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. LPA returned to the above facility on 06/30/2022 and spoke with Administrator, Denise Ordonez via telephone. LPA informed Administrator that a civil penalty in the amount of $100 per day was being assessed until the Plan of Correction (POC) was submitted to the Fresno CCL office. Administrator, Jessica Johnson submitted the POC to the Fresno CCL office on 07/08/2022.

A civil penalty is being assessed for the failure to correct CCR 87465(a)(4) for the period of 06/21/2022 through 07/07/2022 (17 days) in the amount of $100 per day, for a total of $1,700, see form LIC421FC.

An exit interview was conducted. A copy of this report and appeal rights were discussed and provided to Administrator, Jessica Johnson, 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: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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