100400622-12-28-2023-24-AS-LPAT-CYXN9K-20231228091601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100400622
Report Date: 12/27/2023
Date Signed: 12/28/2023 09:16:09 AM

Document Has Been Signed on 12/28/2023 09:16 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	TWILIGHT HAVEN		FACILITY NUMBER:	100400622
ADMINISTRATOR:	LONG, TERESA		FACILITY TYPE:	740
ADDRESS:	1717 SOUTH WINERY AVENUE		TELEPHONE:	(559) 251-8417
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	116	CENSUS: 32	DATE:	12/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Phylicia Smith, Director		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) L. Padgett arrived unannounced to conduct the Annual inspection and Health and Safety check. LPA met with Phylicia Smith, Director (D) and explained the purpose of the visit. Facility was toured with Staff member from Accounts Payable. During this visit, LPA toured the two Assisted Living buildings at this facility. Resident rooms contained required furnishings and lighting. Director explained that shower tile is non skid, that is the reason for absence of Non-skid mats. LPA tested the hot water in two resident rooms; temperature measured 110.2 and 112.6 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required food supply and paper products. Kitchen Supervisor (KS) explained that fresh food is delivered every Friday. At 9:10am LPA observed the ice machine in the kitchen to have some grime on an interior part. KS explained that the ice machine is cleaned once a month. KS called maintenance and the machine was cleaned during LPA’s visit. Since issue was corrected during visit, no deficiency will be cited. Medications are centrally stored and locked in medication room; there is one in each building. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid supplies are located in the medication room and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced in August 2023. Smoke and Carbon Monoxide detectors are to be tested weekly, batteries are changed every 6 months. Smoke Alarms and sprinklers are checked annually with Jorgensen fire safety company, last inspection was 4/13/2023. LPA conducted resident and staff file reviews and interviews. During staff interview LPA was made aware of a bedridden resident in this facility. Currently this facility does not have fire clearance for bedridden residents. LPA reviewed that resident’s current LIC 602A in which the bedridden status has been documented by the resident’s physician. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TWILIGHT HAVEN	FACILITY NUMBER: 100400622
	VISIT DATE: 12/27/2023

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An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Phylicia Smith, Director, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/5/2024 Current copy of Administrator Certificate, Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A).

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/28/2023 09:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: TWILIGHT HAVEN	FACILITY NUMBER: 100400622
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff interview and review of Resident LIC 602A, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4

Section Cited

Levels of Care


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC809 (FAS) - (06/04)

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