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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200356
Report Date: 06/03/2024
Date Signed: 06/03/2024 02:36:57 PM


Document Has Been Signed on 06/03/2024 02:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:MABUHAY GARDENSFACILITY NUMBER:
107200356
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:5046 W. SWIFTTELEPHONE:
(559) 400-8573
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 4DATE:
06/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH: Flora McMurtrieTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Staff (S1) Flora McMurtrie. S1 contacted Licensee Enrique Mayo who authorized S1 to conduct the visit and sign the report. Licensee stated Administrator (AD) Camalah Kopacz would be informed of the visit.

During this visit, LPA toured the facility inside & out. Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathroom was clean and in good repair with faucets delivering hot water, grab bars and non-skid mats were in place. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage as well as Emergency Preparedness supplies. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in the hallway closet. The First aid kits contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced 4/3/24 by Jorgensen Co. Smoke and Carbon Monoxide detectors were tested and found to be in working condition. LPA conducted staff and resident file reviews including P&I logs and medication audit. Emergency Disaster Plan and Infection Control Plans were reviewed during this visit.

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


An exit interview was conducted and Plan of Corrections (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.

See LIC809C for continuation

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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 15


Document Has Been Signed on 06/03/2024 02:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Record review revealed there is no documentation of S1 and S2 Annual training for 2023. Current year documentation is in place, required areas of training are not all met.
POC Due Date: 07/03/2024
Plan of Correction
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AD has agreed to create an annual training checklist to include all areas to receive training annually. A copy of the checklist which states all required areas will be submitted to CCLD by POC date.
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. It is unable to be confirmed that R1 has received appropriate assistance with Fluticasine inhaler. There is no Centrally Stored Log for the medication. The facility has a Medication Administration Record (MAR) that has not been initialed by staff.
POC Due Date: 07/03/2024
Plan of Correction
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AD has agreed to provide training to staff of the facility medication documentation procedures. If the facility uses a MAR, it needs to be complete. All medications need to be documented on a Centrally stored log, complete with start date. Proof of this training (sign in sheet including training description) will be submitted to CCLD by POC 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 15


Document Has Been Signed on 06/03/2024 02:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. R1's Physician Report dated 1/14/2011 marks R1 as having MCI. R1 also has Diabetes which is not noted on the physician's report. The report also notes R1 is not able to provide own glucose testing.
POC Due Date: 07/03/2024
Plan of Correction
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AD has agreed to request and assist in obtaining an accurate Physicians Report. A copy of this report will be provided to CCLD for review by POC date.
Type B
Section Cited
CCR
87705(h)
Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

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, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that the latch on the self release gate needs repair or replacement. The gate was not able to be opened and required repair. The fence needs repair and reinforcement as it is leaning into the neighbors said.
POC Due Date: 07/03/2024
Plan of Correction
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AD has agreed to provide proof of repair. A receipt and pictures will be provided to CCLD by POC 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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 15


Document Has Been Signed on 06/03/2024 02:36 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MABUHAY GARDENS
FACILITY NUMBER: 107200356

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(e)
87217 Safeguards for Resident Cash, Personal Property, and Valuables (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA conducted review of resident P&I. Resident cash on hand was locked and unable to be reviewed. An envelope of "resident allowance" was provided which contained $35.49. S1 stated it was all resident available cash.
POC Due Date: 07/03/2024
Plan of Correction
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AD has agreed to update resident cash availability. Each resident will have their own envelope along with a ledger of available cash to be provided by care staff. A copy of this revised procedure will be submitted to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 14 of 15


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: MABUHAY GARDENS
FACILITY NUMBER: 107200356
VISIT DATE: 06/03/2024
NARRATIVE
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LPA requested the following updated forms faxed to CCLD by 7/3/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E (2019), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024
LIC809 (FAS) - (06/04)
Page: 15 of 15