107200790-10-29-2024-24-AS-JLEL-DAHVXY-20241029165019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107200790
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:50:29 PM

Document Has Been Signed on 10/29/2024 04:50 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:	CLOVIS QUALITY CARE II		FACILITY NUMBER:	107200790
ADMINISTRATOR/ DIRECTOR:	STAGGS, PATRICIA		FACILITY TYPE:	740
ADDRESS:	944 N. CHAPEL HILL		TELEPHONE:	(559) 322-1220
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY: 7	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	10/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Administrator: Katelyn James-Ormsbe		TIME VISIT/ INSPECTION COMPLETED:	05:00 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

On 10/29/24 at 12:30pm Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection LPA was greeted by Administrator-Katelyn James-Ormsbee (A1). LPA introduced self, stated the purpose of the visit. LPA was granted entry. 6 residents were present during inspection.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -13 degrees F and refrigerator temperature was maintained at 39 degrees F. Fire extinguisher was observed with a purchase date of: 12/15/22. Fire drill last completed on 10/3/24. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 109 degrees in bathroom 1 and 110 degrees F. in bathroom 2. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. A sample of medications were checked and observed kept locked in cabinet. Residents’ MARS was reviewed. Based on observation, record review, the licensee did not comply with regulation when LPA and Administrator reviewed resident's MARs and observed the Resident's Mars not completed correctly. The staff stated medications designated for the evening time of 10/29/24 was administered; however the staff initialed medication was given for the resident in care. First aide kit observed with all of the required items.

Samples of staff files reviewed to have all the required documents. Samples of client files reviewed. R1 was missing LIC-627C the Consent Form.

Deficiencies and Technical Violation are being cited on the attached LIC-809D and LIC-9102 in accordance with California Code of Regulations, Title 22,Division 6.

Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 11/12/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report and Appeal Rights were provided to Administrator, whose signature on this form confirms receipt of these reports.

See Moua	TELEPHONE: (559) 580-4596
Jacques Leffall	TELEPHONE: 559-243-8080
	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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 2

Document Has Been Signed on 10/29/2024 04:50 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: CLOVIS QUALITY CARE II	FACILITY NUMBER: 107200790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(3)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, the licensee did not comply with the section cited above when LPA and Administrator reviewed resident's MARs and observed the Resident's Mars not completed correctly. The staff stated medications designated for the evening time of 10/29/24 was administered; however the staff initialed medication was given for the resident in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct medication training with staff and submit completion of medication training to CCLD.

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2