Capistrano Lincoln Street Retreat

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Published
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Contact Information
Licensee Name
Bakersfield Recovery Services Inc.
708 Lincoln Street, Bakersfield, CA 93305
Facility Name
Identification Number
150004GN
Reviews & Findings
Dates of Review
19-Oct-16
Type of Review
COMPLIANCE REVIEW
Deficiencies

1) Title 9, Section 10561(b)(1) Reporting Requirements Class B

The above section states, in part, “Upon the occurrence of any of these events, licensee shall make a telephonic report to department licensing staff within one (1) working day followed by a written report within seven (7) days. Any facility related injury or any resident which requires medical treatment.”

The licensee was deficient in meeting this regulation because the operations manual did not contain a policy regarding resident injury related incidents being reported to the Department.

2) Title 9, Section 10572(a) Health Related Services Class B

The above section states, “The licensee shall ensure that residents receive necessary information about and/or referral to needed medical or dental services.”

The licensee was deficient in meeting this regulation because residents do about and/or referral to needed medical or dental services.

3) Title 9, Section 10573(a)(7) Food Service Class B

The above section states, in part, “All food shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption.”

The licensee was deficient in meeting this regulation because unsealed food items were contained in the kitchen of House A.

4) Title 9, Section 10573(a)(14) Food Service Class B

The above section states, in part, “All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can infect or intoxicate food shall be stored in covered containers at 45 degrees Fahrenheit (7.2 degrees Celsius) or less”

The licensee was deficient in meeting this regulation because all houses did not contain a thermometer within the refrigerators.

5) Title 9, Section 10581(a) Buildings and Grounds Class C

The above section states, in part, “Facilities shall be clean, safe, sanitary, and in good repair at all times.”

The licensee was deficient in meeting this regulation because of the following:
• House A – bedroom 2 contains unfinished patch work, wall scuffs, and peeling paint
• House B – carpet is damaged throughout the house, back entrance door contains a broken door knob
• House C – bedroom 1 contains broken dresser drawer; bedroom 3 contains damaged carpet, damaged dresser, and broken dresser knob
• All Houses – external siding and awning contain rot and other damages

6) Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class B

The above section states, in part, “All window screens shall be in good repair and free of insects, dirt and other debris.”

The licensee was deficient in meeting this regulation because the living room contains a missing window screen in House A

Deficiencies 2

7) Title 9, Section 10584(c) Fixtures, Furniture, Equipment and Supplies Class B

The above section states, in part, “The licensee shall provide lamps or lights as necessary in all rooms and other areas.”

The licensee was deficient in meeting this regulation because of the following:
• House A – bedroom 1 contains missing bulb; bedroom 2 contains missing bulbs
• House B – bathroom contains missing bulb for shower
• Classroom bathroom – contains missing bulb

8) Title 9, Section 10584(e) Fixtures, Furniture, Equipment and Supplies Class B

The above section states, in part, “All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating conditions.”

The licensee was deficient in meeting this regulation because of the following:
• House A – bathroom 1 contains mildew in the shower area, and a rusted medicine cabinet; bathroom 2 contains a broken toilet paper dispenser
• House B – bathroom 1 ceiling vent is broken, bathroom wall contains a large hole, and the bathroom door does not fully lock
• House C – bathroom 1 contains mildew in the shower, damaged linoleum, damaged grout, and damage around window sill
• Classroom bathroom – toilet paper dispenser is broken

Deficiencies 3

1) Section 12015(a) Intake

The above section states, in part, “If a participant is appropriate for treatment, the following information shall be gathered … 7. Previous Treatment.”

The provider was deficient in meeting this standard because previous treatment information was not gathered and/or contained in any participant files.

2) Section 12020 Health Questionnaire

The above section states, in part “Program staff shall review each completed health questionnaire. When appropriate, the participant shall be referred to licensed medical professionals for physical and laboratory examinations. A medical clearance or release shall be obtained prior to admission whenever a participant is referred to licensed medical professionals for physical and laboratory examinations. The referral and clearance shall be documented in the participant’s file.”

The provider was deficient in meeting this standard because referrals and clearances were not documented in any participant files.

Deficiencies 4

3) Section 12050 Referral for Medical or Psychiatric Evaluation and Emergency Services

The above section states, in part, “The program shall have readily available the name, address, and telephone number of the fire department, a crisis center, local law enforcement, and a paramedical unit or ambulance service.”

The provider was deficient in meeting this standard because these services were not posted or provided in any participant files.

4) Section 12055 Referral Arrangements

The above section states, in part, “The program shall maintain and make available to participants a current list of resources within the community that offer services that are not provided within the program. At a minimum, the list of resources shall include medical, dental, mental health, public health, social services and where to apply for the determination of eligibility for State, federal, or county entitlement programs.”

The provider was deficient in meeting this standard because these services were not made readily available.

5) Section 26010(a) Health and Safety

The above section states, in part, “Programs shall be clean, safe, sanitary and in good repair at all limes.”

The provider was deficient in meeting this standard because of the following conditions:
• House A – bedroom 1 contains missing bulb; bedroom 2 contains unfinished patch work, wall scuffs, and peeling paint, missing bulbs; living room contains a missing window screen; bathroom 1 contains
mildew in the shower area, and a rusted medicine cabinet; bathroom 2 contains a broken toilet paper dispenser; unsealed food items were contained in the kitchen.
• House B – carpet is damaged throughout the house, back entrance door contains a broken door knob; bathroom contains missing bulb for shower; bathroom 1 ceiling vent is broken, bathroom wall contains a large hole, and the bathroom door does not fully lock.
• House C – bedroom 1 contains broken dresser drawer; bedroom 3 contains damaged carpet, damaged dresser, and broken dresser knob; bathroom 1 contains mildew in the shower, damaged
linoleum, damaged grout, and damage around window sill.
• Classroom – bathroom contains missing bulb; bathroom toilet paper dispenser is broken.
• All Houses -thermometer was not contained in the refrigerators; external siding and awning contain rot and other damages.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 26
Census: 14

TREATMENT CAPACITY:
Approved: 14
Census: 9