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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005236
Report Date: 02/16/2022
Date Signed: 02/16/2022 11:16:19 AM

Document Has Been Signed on 02/16/2022 11:16 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:KESHER HOUSE, LLC.FACILITY NUMBER:
397005236
ADMINISTRATOR:CAMPBELL, STEVEFACILITY TYPE:
735
ADDRESS:21390 EASTERN HEIGHTS RDTELEPHONE:
(209) 430-8869
CITY:LINDENSTATE: CAZIP CODE:
95236
CAPACITY: 5CENSUS: 3DATE:
02/16/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Jeffrie Chairez, Assistant AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
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On 02/16/2022 at 9:25am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Assistant Administrator, Jeffrie Chairez and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 5 clients.

LPA White inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility. Facility has a formal dining room and TV room for clients. There is a large backyard area with separate game room for clients. Game room was inspected to be clean, sanitary and safe.

The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed.

Hot water temperature reads 130*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Smoke and carbon detectors were in operating condition. Fire extinguisher was checked 7/22/21. All toxins and dangerous items are inaccessible to clients in care. LPA reviewed 2 staff files and 2 client files.

LPA observed the following deficiency:
- Hot water temperature measured at 130 degrees F.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Assistant Administrator Jeffrie Chairez. A copy of report and appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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Document Has Been Signed on 02/16/2022 11:16 AM - It Cannot Be Edited


Created By: Treana White On 02/16/2022 at 10:56 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: KESHER HOUSE, LLC.
FACILITY NUMBER: 397005236

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited
CCR
80088(e)(1)

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80088(e)(1): Furniture, Fixtures...: (e)Faucets used by clients for personal care...
(1) Hot water temperature... shall be not less than 105 degrees F... and not more than 120 degrees F..
This requirement was not met as evidence by:
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Assistance Administrator adjusted the hot water heater. LPA checked hot water which measured at 113.3 degrees F.

Deficiency cleared during inspection.
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Based on observation, facility did not comply with the section cited above in 80088(e)(1). LPA observed hot water temperature measured at 130 degrees F. which poses as an immediate health and safety risks to clients 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:Liza King
LICENSING EVALUATOR NAME:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


LIC809 (FAS) - (06/04)
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