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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206591
Report Date: 06/22/2022
Date Signed: 06/23/2022 09:00:19 AM

Document Has Been Signed on 06/23/2022 09:00 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ARCADIA FAMILY CAREFACILITY NUMBER:
157206591
ADMINISTRATOR:YATCO, JERRYFACILITY TYPE:
740
ADDRESS:8306 SHIPROCK DRIVETELEPHONE:
(661) 587-0370
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY: 6CENSUS: 6DATE:
06/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Olivia RouraTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management in conjunction with a 10-Day complaint visit. LPA met with and explained the purpose of the Case Management with Facility Designee, Olivia Raura as the facility Administrator was unavailable.

During the visit, LPA toured the facility and observed chemicals and cleaning supplies in the laundry room and under the kitchen sink that were accessible to residents and not locked up.

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.






A copy of this report including Plan of Correction and Appeal Rights were provided via email to jasireejustin@yahoo.com.

An exit interview was conducted with Olivia Raura who authorized Care Provider Rose Treyes to sign the visit reports.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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 06/23/2022 09:00 AM - It Cannot Be Edited


Created By: Katie Brown On 06/22/2022 at 02:08 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: ARCADIA FAMILY CARE
FACILITY NUMBER: 157206591

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2022
Section Cited
CCR
87309(a)(1)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement was not met as evidenced by:
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The facility staff secured the chemicals, paint and cleaning supplies to a locked cabinet during the visit. The facility has agreed to provide training to staff regarding chemical storage. In addition, pictures will be submitted to CCLD of the permanant locked location of the laundry room chemicals and supplies.
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Licensee did not ensure that disinfectants, cleaning solutions and other items which could pose a danger were inaccessable to clients. LPA observed paint, cleaning supplies and chemicals unlocked in the laundry room and under the kitchen sink.

This poses an immediate health and safety risk to persons in care.
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 Proof of training in the form of a staff sign in sheet and pictures will be provided to CCLD via email by 7/6/2022. Email and contact information were provided.

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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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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