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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100408901
Report Date: 10/12/2021
Date Signed: 10/13/2021 09:44:47 AM

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:GARDEN MANORFACILITY NUMBER:
100408901
ADMINISTRATOR:BLACK, JOANFACILITY TYPE:
740
ADDRESS:4983 E. OLIVETELEPHONE:
(559) 255-8650
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:49CENSUS: 41DATE:
10/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Bonnie Martin, CaregiverTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) K. Kaur and M.Yang conducted an unannounced case management inspection regarding an incident report that was received in the CCL Office. LPA(s) met caregiver Bonnie Martin and stated the purpose of the inspection. Administrator Joan Black was unavailable and permission was given to Bonnie Martin to sign the report. The incident report stated that the resident AWOL from facility on 9/12/2021. Fresno PD was contacted.

LPA reviewed Police report and physician report. Per the physician report resident cannot leave the facility unassisted. Please see the attached 809D for deficiency for care and supervision immediate civil penalty of $500 is assessed.

Exit Interview conducted and appeal rights were provided.

Due to COVID 19 precautionary measures this report and appeal letter will emailed to facility. Report signed on Site.


SUPERVISOR'S NAME: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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: GARDEN MANOR
FACILITY NUMBER: 100408901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2021
Section Cited

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87411(a) Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidenced by
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Based on records review R1, who cannot leave the facility unassisted, AWOL from the facility without facility staff’s knowledge, which posed an immediate health and safety risk to the resident. Immediate penalty was also assessed.
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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: Brenda WhiteTELEPHONE: (550) 243-8080
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2021
LIC809 (FAS) - (06/04)
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