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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202394
Report Date: 06/28/2022
Date Signed: 06/28/2022 02:42:31 PM

Document Has Been Signed on 06/28/2022 02:42 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:KAISER SPECIALIZED RESIDENTIAL CONSTITUTIONFACILITY NUMBER:
547202394
ADMINISTRATOR:ADAN SEGURAFACILITY TYPE:
735
ADDRESS:1268 CONSTITUTION STTELEPHONE:
(559) 685-9006
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 5CENSUS: 5DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Adan Segura, AdministratorTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Adan Segura. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the kitchen. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked. Cleaning and PPE supplies were checked. Records were reviewed for infection control training. Facility staff was observed with mask on. Resident’s files have updated emergency contact information.

Deficiency cited on LIC809D.

Exit interview was conducted. A copy of this report and Appeal rights were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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 06/28/2022 02:42 PM - It Cannot Be Edited


Created By: Lady Cabrera On 06/28/2022 at 02:22 PM
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: KAISER SPECIALIZED RESIDENTIAL CONSTITUTION
FACILITY NUMBER: 547202394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above. LPA observed room #3 to have punched walls and in the common area, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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Licensee will punched walls in room #3 and common area by 07/08/2022. Licensee will submit photos to CCL by 07/08/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: KAISER SPECIALIZED RESIDENTIAL CONSTITUTION
FACILITY NUMBER: 547202394
VISIT DATE: 06/28/2022
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Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Adult Residential Facility (ARF):


· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan For Adult Residential Facilities
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Administrator Certificate


Please submit the above forms/information to Fresno CCL by: 07/08/2022.

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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