100400544-4-15-2021-24-AS-AWAN-C24TFL-20210415144144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100400544
Report Date: 04/15/2021
Date Signed: 04/15/2021 02:42:34 PM

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:	TERRACES AT SAN JOAQUIN GARDENS, THE		FACILITY NUMBER:	100400544
ADMINISTRATOR:	SHAUN RUSHFORTH		FACILITY TYPE:	741
ADDRESS:	5555 NORTH FRESNO STREET		TELEPHONE:	(559) 439-4770
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	652	CENSUS: 350	DATE:	04/15/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	02:11 PM
MET WITH:	Executive Director, Shaun Rushforth		TIME COMPLETED:	02:50 PM

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On 4/15/2021, Licensing Program Analyst (LPA) A. Walton contacted Executive Director (ED), Shaun Rushforth to conduct a Case Management – Deficiencies visit via telephone due to COVID-19 and precautionary measures. LPA introduced self and discussed the purpose of the call with the ED.

During the course of a complaint investigation, the following deficiency was observed.

Residents at the above facility, were asked to push a button each morning that would notify staff that they are okay. If facility staff did not hear from a resident by a specific time each day, the facility would conduct a wellness check. On 5/15/2020 and 5/16/2020, facility staff conducted wellness checks for R1, after R1 did not push the button to notify staff.

On 5/15/2020, S2 arrived at R1’s apartment to conduct a wellness check. S2 knocked on R1’s door and waited for R1 to respond. When R1 did not respond, S2 entered R1’s apartment. Per S2, R1 was in the bathroom and reported “being okay”, but, was “barely talking”. S2 informed S6 and requested that S6 conduct a follow up to check on R1. S6 was called away for an emergency that “trickled all day” and did not conduct the follow up.

On 5/16/2020, S3 conducted a wellness check, as R1 did not push the button to check in with facility staff. S3 knocked on R1’s door, waited for a response, and entered R1’s apartment when R1 did not respond. Per S3, R1 was in the bathroom and reported “being okay”, but, was out of breath. S3 requested a follow up. S5 conducted a follow up, but, was sent to the wrong apartment and cleared the wrong resident.

Continued to LIC809C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TERRACES AT SAN JOAQUIN GARDENS, THE	FACILITY NUMBER: 100400544
	VISIT DATE: 04/15/2021

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At approximately 7:30 PM on 5/16/2020, R1’s family requested a wellness check for R1 and when R1’s family could not reach R1. S1 conducted the wellness check, and found R1 lying on the bathroom floor, unclothed and in urine. S1 assessed R1 and observed bruising to R1’s back and lower buttocks. Records revealed R1 was treated for a pressure ulcer, unspecified stage, deep tissue community acquired pressure injury, and dehydration.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 809D. An immediate civil penalty is being assessed in the amount of $500 in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted with Executive Director. Appeal Rights and a copy of this report was discussed and provided via email and an electronic read receipt confirms receiving these documents. Facility representative signature on file.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TERRACES AT SAN JOAQUIN GARDENS, THE	FACILITY NUMBER: 100400544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/16/2021 Section Cited	1 2 3 4 5 6 7	87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on record reviews and interviews conducted: on 5/15/20 and 5/16/20, S1 and S3 requested follow up wellness checks of R1 and none were conducted with R1. This poses an immediate risk to the health and safety of residents in care. Civil penalty assessed.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC809 (FAS) - (06/04)

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