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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209321
Report Date: 10/26/2023
Date Signed: 10/26/2023 05:40:40 PM

Document Has Been Signed on 10/26/2023 05:40 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:EBONY HOME LLCFACILITY NUMBER:
547209321
ADMINISTRATOR:THOMPSON, JENNIFERFACILITY TYPE:
735
ADDRESS:669 WEST KANAI AVETELEPHONE:
(559) 310-0271
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY: 4CENSUS: 4DATE:
10/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Francis BeardsleyTIME COMPLETED:
05:56 PM
NARRATIVE
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LPA, L. Xiong was at the above facility conducting a case management visit to follow-up on an incident occurred on 10/24/23. I met with staff Francis Beardsley and spoke to Administrator Jennifer Thompson on the phone and informed them the purpose of the visit.

LPA interviewed S1 and S2 and reviewed the file of R1 during the visit.

The following deficiency is in violation of title 22 div. 6 CCR.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Les Xiong
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/26/2023 05:40 PM - It Cannot Be Edited


Created By: Les Xiong On 10/26/2023 at 05:17 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: EBONY HOME LLC
FACILITY NUMBER: 547209321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the client's needs. Due to the needs of the residents, the facility require night staff to be awake. LPA observed staff S2 fell asleep and R1 exited the facility unnoticed during the incident.
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Per Administrator, in-service training on AWOL will be provided to facility staff by 11/9/23 and email the training & staff sign-in sheet to Community Care Licensing.

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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:Les Xiong
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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