100408901-12-16-2024-24-AS-RABE-DC256R-20241216184110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 100408901
Report Date: 12/16/2024
Date Signed: 12/16/2024 06:49:23 PM

Document Has Been Signed on 12/16/2024 06:49 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/ DIRECTOR:	BLACK, JOAN		FACILITY TYPE:	740
ADDRESS:	4983 E. OLIVE		TELEPHONE:	(559) 255-8650
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY: 49	TOTAL ENROLLED CHILDREN: 0	CENSUS: 40	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:03 AM
MET WITH:	Joanna Tilghman, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA met with Assistant Administrator Joanna Tilghman (AA) and explained the purpose of the visit. Facility was toured with AA, including main house, garage and storage areas, outside recreational area, and six resident building units. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms. Resident hygiene supplies were properly stored and available as well as extra linen, and overflow of necessary items. In the main house the bathroom water temperature was 108 degrees F. In building 105 the bathroom water temp 108.9 degrees F. In building 106 the bathroom was in use no test was conducted. In building 104 the bathroom water temperature was 106.3 degrees F. In building 103 the bathroom water temperature was 105.4 degrees F. In building 102 the bathroom water temperature measured 104.7 degrees F and in building 101 the bathroom water temperature was 100 degree F. The kitchen was toured and observed to be 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. There is a dry storage area kept locked outside the general kitchen area. Canned foods are ordered and delivered on a regular basis however the cans expiration date is listed on the delivery box and not the individual cans. LPA was unable to determine the freshness of food in storage. There are 2 refrigerators in the storage/garage area that hold overflow. Medications are centrally stored and locked. Medical review of distribution records and pill count was completed by LPA. For 11 residents LPA found errors in the distribution. There were no initials only an "X" so there was no way of knowing who gave the medication and secondly there were missing doses and no indication of why, i.e. resident was in hospital, resident refused etc. The AA indicated in those instances it appears to be staff error. First aid supplies located in Main House and found to contain required items. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. The backyard is clean and provides ample space for residents to walk or recreate. Seating is available as well.

Sergiy Pidgirny	TELEPHONE: (559) 246-0610
Rachel A Bruce	TELEPHONE: (559) 470-9001
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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 4

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: 12/16/2024

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

Fire Extinguishers are located throughout the facility and were serviced by Valley Fire on 6/7/2024. Per Facility record there are 30 smoke detectors which are checked and batteries replaced as needed by maintenance. Records of smoke alarm checks can be found in maintenance binder. Last documented inspection was June 3, 2024. LPA reviewed Jorgensen & Co. Fire Alarm System Service Report dated September 13, 2024. On that date sprinklers were inspected by the Fire Department and Jorgensen jointly. The report indicates the facility failed the inspection due to an issue with 2 automatic sprinkler heads located outside. The necessary repair/replacement was completed and a re-inspection completed on 12/10/24. AA will forward successful report to CCL when received.

Administration certifications are current.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and will be provided to AA. At the time the inspection was over, AA was not available to sign so Bonnie Martin, House Manager was given permission to sign.

LPA is requesting the following documents be submitted to the Fresno CCL office by 1/12/2025: 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), and Register of Facility Clients/Residents for (LIC9020A).

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Rachel A Bruce	TELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 12/16/2024 06:49 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: 12/16/2024

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
1 2 3 4	Based on observation and record review it was found that staff were not always marking when medication was dispensed. It was also noted that no initials are used only an "X" which provides no indication of who dispensed medication. This practice poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/20/2024
	Plan of Correction
1 2 3 4	AA stated she will immediately meet with staff and provide training and develop a more comprehensive procedure clearly delineating who provided the medication and when it is not given, provide a reason why. Proof of training and material covered will be provided to CCL by the due date of 12/20/2024.

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.

Sergiy Pidgirny	TELEPHONE: (559) 246-0610
Rachel A Bruce	TELEPHONE: (559) 470-9001
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 12/16/2024 06:49 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: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA was not able to ascertain the freshness of the non-perishable food as expiration dates are not present. This practiced poses a potential risk to the health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2025
	Plan of Correction
1 2 3 4	AA will develop a new procedure to ensure that the pull dates are noted and marked clearly so there will be no question of expiration dates. Procedure to be developed and plan sent to CCL by the due date of January 5, 2025.

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.

Sergiy Pidgirny	TELEPHONE: (559) 246-0610
Rachel A Bruce	TELEPHONE: (559) 470-9001
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4