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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
100405566
Report Date:
01/14/2025
Date Signed:
01/14/2025 05:55:42 PM
Document Has Been Signed on
01/14/2025 05:55 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
FRESNO RO
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
ADMINISTRATOR/
DIRECTOR:
PRINCE, BETTY
FACILITY TYPE:
740
ADDRESS:
4686 E CORTLAND
TELEPHONE:
(559) 231-5728
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93726
CAPACITY:
6
TOTAL ENROLLED CHILDREN:
0
CENSUS:
4
DATE:
01/14/2025
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:
Administrator: Betty Prince
TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 1/14/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Licensee (L1) Betty Prince. LPA was granted entry. No residents were present upon arrival but arrived from day program later during inspection.
LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -4 degrees F and refrigerator temperature was maintained at 37 degrees F. Fire extinguisher was observed with a purchase date of: 7/25/24. No fire drill was completed and no record obtained during inspection. Washer was observed not operational and dryer observed operational during visit. Carbon monoxide not present in facility, and smoke detector was tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. 1 bathroom toured and observed to be operational, however toilet paper roll, bugs, liners, diapers were observed on top of bathroom sink. Hot water temperature was tested at a temperature of 115.8 degrees F. Non-skid mat and grab bars observed in bathroom shower, however bathroom floor and tile is in need of repair. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. Backyard contained debris throughout and contained debris on patio table. Medications was not checked because Licensee did not have MARS present at facility for review. First aide kit observed with all the required items.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 resident's Identification/Emergency Contact form LIC-601 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to submit copies of completed LIC-601 to Fresno CCL by POC due date.
Section Cited
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above in 1 out of 1 bathroom sink containing used toilet paper roll, bugs, diapers and liners, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to maintain, clean, bathroom sink clear of unsanitary products and submit a photo of clean sink to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (A) Gloves shall always be worn when: 4. Administering first aid.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 First Aide certificate on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to have First Aide updated and agrees to submit written documentation of completed First Aide.
Section Cited
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in 1 out of 1 carbon monoxide detector not present in facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to replace or obtain new carbon monoxide detector submits Licensee to submit written documentation of a purchased carbon monoxide detector.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in 1 out of 1 kitchen floor tile needs replacing or repair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to repair or replace kitchen floor and submit a photo of repair to Fresno CCL by POC due date.
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. (A) All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 shower floor/tile needs repairing or replacing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to repair or replace tile and shower floor and submit photo of repair to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above in 1 out of 1 backyard contains debris and overall is not clean which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to clean and clear backyard of all debris and submit photos to Fresno CCL by POC due date.
Section Cited
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 staff files including First Aide Certification, Facility Sketch, and Fire Drill log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2024
Plan of Correction
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Licensee agrees to submit copies of First Aide Certification, posted Facility Sketch, and Completed Fire Drill log to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 MARS was not present in facility for review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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Licensee agrees to complete Medication training and submit documentation of completed documentation to Fresno CCL by POC due date.
Section Cited
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 MARS was not present in facility for review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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2
3
4
Licensee agrees to complete Medication training and submit documentation of completed documentation to Fresno CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
01/14/2025 05:55 PM
- 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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/14/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, and record review, the licensee did not comply with the section cited above in 1 out of 4 out of residents is missing the Identification/Emergency contact LIC-601, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/15/2025
Plan of Correction
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2
3
4
Licensee agrees to have LIC-601 form on file in facility. Once complete, Licensee agrees to send form to Fresno CCL by POC due date.
Section Cited
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.
See Moua
TELEPHONE:
(559) 580-4596
Jacques Leffall
TELEPHONE:
559-243-8080
DATE:
01/14/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
7
of
8
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:
PRINCE & PRINCESS HOME FOR THE ELDERLY
FACILITY NUMBER:
100405566
VISIT DATE:
01/14/2025
NARRATIVE
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All residents files reviewed. 1 out of 4 resident is missing Identification/Emergency Contact form and Fire Drill completion log. Staff file reviewed and is missing current First Aide certification, and posted Facility Sketch.
The following deficiencies are being cited on the attached 809D forms in accordance to California Code of Regulations, Title 22, Division 6. Technical Support Services were referred offered and Licensee agrees to utilize services.
Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 1/28/25: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report with Appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME:
See Moua
TELEPHONE:
(559) 580-4596
LICENSING EVALUATOR NAME:
Jacques Leffall
TELEPHONE:
559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/14/2025
LIC809
(FAS) - (06/04)
Page:
8
of
8