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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 355202781
Report Date: 01/12/2024
Date Signed: 01/17/2024 09:11:40 AM

Document Has Been Signed on 01/17/2024 09:11 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BAUTISTA HOMEFACILITY NUMBER:
355202781
ADMINISTRATOR:MITCHELL GUEVARAFACILITY TYPE:
737
ADDRESS:777 OLYMPIATELEPHONE:
(831) 818-7981
CITY:SAN JAUN BAUTISTASTATE: CAZIP CODE:
95045
CAPACITY: 4CENSUS: 4DATE:
01/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Catrina Bravo, Lead RBTTIME COMPLETED:
12:26 PM
NARRATIVE
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On 01/12/2024, Licensing Program Analyst (LPA) Gorban conducted a case management in response to the complaint Licensing Department received on 09/20/23 in regard to inconsistency in maintaining of clients’ records.

LPA Gorban met with facility Lead RBT, stated the purpose of the visit, and was allowed entry into the facility.

During this visit LPA Gorban toured the facility inside and out, observed clients in care and reviewed clients’ facility files.

LPA discussed with administrator following. During facility records review provided by Director of operations, David Sandhu discrepancy noted by DO. Facility records for C1 appear to have discrepancy on the documentation of client’s funds spent. On 9/19/23 and 9/21/23 appear to have a discrepancy in monetary records documented.

Facility failed, following title 22, to maintain clients accurate records.

Continuation of this report will be issued a deficiency during this visit on LIC809-D

Exit interview conducted. Report signed and a copy of this report with appeal rights provided to administrator for facility records.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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 01/17/2024 09:11 AM - It Cannot Be Edited


Created By: Vadim Gorban On 01/12/2024 at 10:18 AM
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: BAUTISTA HOME
FACILITY NUMBER: 355202781

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
80026(h)

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80026 Safeguards for Cash Resources.
(h) Each licensee shall maintain accurate records of accounts of cash resources. This was not met as evidenced by
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plan of correction was discussed with facility Lead. All P&I have to be documented with Leads presence on a smart sheet. Meeting was conducted and P&I records issue was address. P&I training was conducted and all staff completed the training.
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Based on records review provided by facility director of Operations, clients documented cash resources on 9/19/ and 9/21 appear discrepancy in cash records on LIC405. This is posses potential personal rights violation 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 Chan
LICENSING EVALUATOR NAME:Vadim Gorban
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


LIC809 (FAS) - (06/04)
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