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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107200356
Report Date: 07/20/2023
Date Signed: 07/21/2023 09:12:21 AM


Document Has Been Signed on 07/21/2023 09:12 AM - 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:MAYO, ENRIQUEFACILITY TYPE:
740
ADDRESS:5046 W. SWIFTTELEPHONE:
(559) 400-8573
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 3DATE:
07/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Linda MateoTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Enrique Mayo. Administrator Camalah Kopacz was unable to attend the visit.

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms which were clean. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguisher service date 5/15/23. Last Fire Drill conducted 3/3/23. Hot water temperature in resident bathroom measured 105 degrees F. Staff and resident file reviews and interviews were conducted.

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 Correction (POC) was developed. A copy of this report and Appeal Rights were discussed with and emailed to Enrique Mayo and Camalah Kopacz.

LPA requested the following updated forms faxed to CCLD by 7/31/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500), 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: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
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 2


Document Has Been Signed on 07/21/2023 09:12 AM - 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: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

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 a potential health, safety or personal rights risk to persons in care. LPA reviewed the facility Medicarion Administration Record (MAR). PRN medications are not noted on the MAR and based on interview, the complete PRN log is not used. Additionally, the Centrally Stored log is not filled in or complete. The MAR has not been initialed 7/18-7/20/23.
POC Due Date: 07/31/2023
Plan of Correction
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Facility has agreed to conduct in-service to all staff who assist with medication management. In-Service will consist of review of facility documentation procedures to ensure completeness and accuracy of medications passed. To be reviewed: PRN Log, Centrally Stored Log, MAR completeness. A copy of in-service sign in and materials used will be submitted to include topics, date, timing, trainer, name & signature of staff will be submitted to CCLD by POC date.
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (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 the licensee did not comply with the section cited above. The doors leading to the backyard from resident rooms is obstructed by furniture in rooms 1, 2, 3, 4 and the Master/staff room. Additionally, the kitchen walkway to the backyard is obstructed by a supply cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Facility has agreed to move furniture in all named rooms, including the kitchen to allow for passageways to be clear and free of obstruction. A picture of the rooms and kitchen with unobstructed passageways will be emailed to CCLD by the 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: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023
LIC809 (FAS) - (06/04)
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