107200790-12-15-2022-24-AS-MYAG-CM5TJU-20221215134656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107200790
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:47:38 PM

Document Has Been Signed on 12/15/2022 01:47 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:	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: 4	DATE:	12/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Caregiver Lydia Garcia and Licensee Patricia Staggs via telephone		TIME COMPLETED:	01:45 PM

NARRATIVE

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On 12/15/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Lydia Garcia, staff. Licensee Patricia Staggs was called and unable to attend meeting. Licensee authorized staff to received and signed report. LPA conducted tour with staff. All 4 residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. 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. COVID-19 related signs and cough etiquette posting observed.

LPA observed fire extinguisher served date: 05/08/21. LPA checked residents’ locked medications. LPA observed small amount of PPE supplies in facility. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in laundry room.All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and 1 vacant bedroom. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with no lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Side gate was self-closing and self-latching. Three of four resident records reviewed to have updated emergency contact information. Staff records were reviewed staff that was present during inspection did not have current CPR/First Aid certification.

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

An exit Interview conducted with staff and Licensee via telephone. The following documents are requested and submitted to Fresno CCL by: 12/21/22. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, and current liability insurance. A copy of this report and appeal rights was provided to Licensee via email. Report signed on site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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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Document Has Been Signed on 12/15/2022 01:47 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: CLOVIS QUALITY CARE II	FACILITY NUMBER: 107200790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a service date of 05/08/21, which poses an immediate health and safety risk to the residents.
	POC Due Date: 12/16/2022
	Plan of Correction
1 2 3 4	Licensee shall have fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 12/16/22.

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) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/15/2022 01:47 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: CLOVIS QUALITY CARE II	FACILITY NUMBER: 107200790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 LPA reviewed and observed staff records. LPA and staff observed S1 who was providing resident care and supervision during inspection did not have current CPR certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2022
	Plan of Correction
1 2 3 4	Licensee shall submit to CCLD Fresno by the 12/21/22, copy of CPR certification for S1.

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) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC809 (FAS) - (06/04)

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