107200790-11-5-2021-24-AS-MYAG-C8GT8U-20211105143052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107200790
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:31:58 PM

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:	CLOVIS QUALITY CARE II		FACILITY NUMBER:	107200790
ADMINISTRATOR:	STAGGS, PATRICIA		FACILITY TYPE:	740
ADDRESS:	944 N. CHAPEL HILL		TELEPHONE:	(559) 322-1220
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	7	CENSUS: 5	DATE:	11/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Lydia Garcia and Nancy Silva, caregivers		TIME COMPLETED:	10:55 AM

NARRATIVE

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On 11/05/2021, Licensing Program Analysts (LPAs) M. Yang and K. Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPAs met with caregivers, Lydia Garcia and Nancy Silva. Licensee Patricia Staggs was called and authorized caregivers to conduct inspection and receive report. All four residents were present during the inspection.

LPAs conducted tour with caregivers. Facility staffs was observed with mask on. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPAs observed social distancing postings in facility. LPAs observed fire extinguisher served date: 05/08/21. LPAs checked residents’ locked medications. LPAs did not observe a 30-day PPE supply. Food supply was checked and appeared to be an adequate supply.

All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPAs observed hand washing posting by all sinks. LPAs observed a bleach bottle and Comet cleaning chemical bottle stored in an unlocked laundry room. All bedrooms are furnished and adequately lit. LPAs observed 1 shared resident’s bedroom to be at least 6 feet apart, 2 bedrooms that are single occupant, and 1 vacant bedroom.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information. LPAs reviewed LIC 808 including Infection control procedures to be implemented and in placed. Copy of completed LIC 808 Mitigation Plan to be submitted to CCL by 11/11/21.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/11/21. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, and current liability insurance. LPAs received copy of Administrator Certificate during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report and appeal letterwill be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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: CLOVIS QUALITY CARE II	FACILITY NUMBER: 107200790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/05/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 when LPAs observed a bleach bottle and 2 opened Comet cleaning chemical bottles stored in an unlocked laundry cabinet in the laundry room accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2021
	Plan of Correction
1 2 3 4	Caregiver immediately locked the laundry room that stored the bleach bottle and the 2 opened Comet cleaning chemical bottles. POC cleared during visit.

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.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

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