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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201578
Report Date: 08/19/2022
Date Signed: 09/13/2022 02:52:46 PM

Document Has Been Signed on 09/13/2022 02:52 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:WILLIAMS WHITTLE RESIDENTIAL CARE HOME #3FACILITY NUMBER:
107201578
ADMINISTRATOR:WHITTLE, CHERYL AFACILITY TYPE:
740
ADDRESS:4093 W. TERRACE AVENUETELEPHONE:
(559) 271-2152
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Lucille WilliamsTIME COMPLETED:
02:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management in conjunction with am Annual Inspection. LPA met with and explained the purpose of the Case Management with Lucille Williams.

During the visit, LPA toured the facility and observed the following:
1. Sliding Screen door in Resident (R1's) room and outside the living room are in disrepair
2. Blinds in the kitchen are in disrepair
3. Residents R1 and R2 files were incomplete


The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.

An exit interview was conducted and Plan of Correction was developed and reviewed. A copy of this report and Appeal Rights were discussed and provided to Lucille Williams, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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 09/13/2022 02:52 PM - It Cannot Be Edited


Created By: Katie Brown On 08/19/2022 at 03:04 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: WILLIAMS WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER: 107201578

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
CCR
80087(a)

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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 was not met as evidenced by:
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Facility has agreed to replace the screens for the sliding door, living room window and both kitchen window blinds and provide a picture of the repaired items to the LPA via email by 8/31/2022
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Licensee did not ensure the facility was clean, safe, sanitary and in good repair for the safety and well being of clients, employees and visitors. LPA observed the screen of R1's sliding door is torn and off the track, window screens outside TV room is bent and both kitchen window blinds are in disrepair and dirty.

This poses a potential Health, safety or residents rights risk to persons in care.
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Type B
08/31/2022
Section Cited
CCR80070(a)

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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement was not met as evidenced by:
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Facility has agreed to conduct an audit of 3/3 resident files. Using LIC811, facility will add and/or update resident files to be complete and current. The facility will submit a "checklist" for each resident to show that all required items have been placed. Each checklist will contain resident's name and the date. Checklists will be emailed to LPA by 8/31/2022
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Licensee did not ensure that 3/3 resident files were complete and current. LPA observed that R1 and R2 resident files did not contain all required documents. Resident emergency contact information needs to be updated in the event of an emergency for medical personnel.

This poses a potential health, safety and resident rights risks to persons 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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2022


LIC809 (FAS) - (06/04)
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