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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547206729
Report Date: 04/11/2024
Date Signed: 04/11/2024 09:50:04 PM

Document Has Been Signed on 04/11/2024 09:50 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:SPECIALIZED RESIDENTIAL CHERYL LANEFACILITY NUMBER:
547206729
ADMINISTRATOR/
DIRECTOR:		NORALBA MAGANAFACILITY TYPE:
735
ADDRESS:1740 CHERYL LNTELEPHONE:
(559) 686-2593
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 6CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:31 AM
MET WITH:Nora Alba, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 04/11/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on LPAs previous visits and an incident report dated 04/11/24. LPA was greeted by Staff S1, stated the purpose of the visit and was allowed entry into the home. Administrator was called and arrived shortly after.

On 01/25/24, LPA reviewed records and observed Resident R1’s Needs and Service plan. Records show R1 to have 1:1 staffing needs (24/7). Based on interviews with staff and further records review. R1 has not had 1:1 staffing while residing in the facility.

Per California Code of Regulations, Title 22, Division 6, a deficiency is being cited on the attached 809-D. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care.



An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided via email on 04/12/2024.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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 04/11/2024 09:50 PM - It Cannot Be Edited


Created By: Lisa Salazar On 04/11/2024 at 03:49 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: SPECIALIZED RESIDENTIAL CHERYL LANE
FACILITY NUMBER: 547206729

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2024
Section Cited
CCR
80065(a)

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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
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Administrator has assigned a 1:1 staff with Resident R1. R1 and R2 have not had an altercation since 1:1 staffing. **POC cleared**
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This requirement was not met as evidenced by LPAs observation of incident report dated12/4/23, interview with staff. Resident R1 and R2 are requiring additonal staffing when together. If not corrected, this poses an immediate risk to the Health, Safety and personal rights of 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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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