100408901-1-8-2024-24-AS-LPAT-CZAUDB-20240108142916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100408901
Report Date: 01/04/2024
Date Signed: 01/08/2024 02:29:25 PM

Document Has Been Signed on 01/08/2024 02:29 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:	GARDEN MANOR		FACILITY NUMBER:	100408901
ADMINISTRATOR:	BLACK, JOAN		FACILITY TYPE:	740
ADDRESS:	4983 E. OLIVE		TELEPHONE:	(559) 255-8650
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	49	CENSUS: 35	DATE:	01/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Joanna Tilghman, Assistant Administrator		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 Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Assistant Administrator Joanna Tilghman (AD) and explained the purpose of the visit. Facility was toured with AD. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms. Resident hygiene supplies were properly stored and available. In building 104 the bathroom water temperature was 144 degrees F. In building 105 the bathroom water temp 119.2 degrees F. In building 106 the bathroom water temperature was 127.1 degrees F. The kitchen was toured observed in good repair with necessary items and appliances. Sharps/knives are stored in drawer, but doors leading to kitchen are kept locked. LPA observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid supplies located in office and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced by Valley Fire on 7/17/2023. Per Facility record there are 30 smoke detectors and they were last checked and batteries changed on 10/5/2023. LPA reviewed Jorgensen & Co. Fire Alarm System Service Report dated 8/14/2023. This Report states this facility did not pass inspection. During this visit AD called Jorgensen and requested service to replace items not in compliance. Sprinklers were last inspected by the Fire Dept. on 8/14/2023. Administrator’s re-certification was confirmed to be in active status. 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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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 3

Document Has Been Signed on 01/08/2024 02:29 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: GARDEN MANOR	FACILITY NUMBER: 100408901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed Fire Alarm System Service Report dated 8/14/2023 which states this facility did not pass inspection.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	AD has contacted the Jorgensen & Co Company and made a service request to replace items not in compliance.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA tested the water temperature in the resident bathrooms, two were found to be too hot at 144 and 127.1 degrees F.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Licensee will contact maintence to lower water temperatures. Licensee will check water temperature in all buildings to ensure theu are in compliance. Licensee will contact LPA to recheck the water temperatures.

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: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: GARDEN MANOR	FACILITY NUMBER: 100408901
	VISIT DATE: 01/04/2024

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
26
27
28
29
30
31
32

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 AD, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/12/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3