107200907-6-22-2021-24-AS-AWAN-C492ET-20210622172029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107200907
Report Date: 06/22/2021
Date Signed: 06/22/2021 05:21:45 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:	EDDIE'S TERRACE		FACILITY NUMBER:	107200907
ADMINISTRATOR:	HENDRICKS, STEPHANIE		FACILITY TYPE:	735
ADDRESS:	2693 SOUTH BARDELL AVENUE		TELEPHONE:	(559) 485-4911
CITY:	FRESNO	STATE: CA	ZIP CODE:	93706
CAPACITY:	6	CENSUS: 4	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:	Caregiver, Daisy Miranda		TIME COMPLETED:	02:45 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 06/22/2021, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and requested to speak with the Administrator. Administrator, Maricia Alvarado was contacted via telephone and is unable to attend this inspection. LPA received verbal permission to conduct the facility tour with Caregiver, Daisy Miranda. Upon entry to the facility, LPA was screened. LPA observed visitor log-in/screening log. Facility has one central entry and exit. There are four residents present during this inspection. LPA observed facility staff improperly wearing facial coverings. LPA conducted a tour of the facility with Caregiver. Tour began in the kitchen. LPA observed a 7-day supply of non-perishable food items and a 2-day supply of perishable food items. LPA observed the bottom cover to the refrigerator to be missing. One of the blinds in the dining area was observed to be missing. LPA observed a bottle of bleach under the kitchen sink, accessible to residents. Caregiver removed the bottle of bleach from under the sink and placed the bottle in a secure location. Facility pathways were clear of obstructions. Entrances/exits were clear, no fire clearance issues observed during this visit. Facility does not have signs posted throughout the facility promoting social distancing, hand-washing, and cough/sneeze etiquette. Resident bedrooms checked. Bedrooms are single occupant. Bathrooms were stocked with paper towels and liquid soap. LPA smelled a strong odor of urine in bathroom 1. Exterior tour of facility conducted. LPA observed a large, iron gate broken on the east side of the facility. The iron gate was unable to close allowing access to the front of the facility. The facility van was utilized to block the entry/exit CONTINUED TO LIC809C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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 4

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: EDDIE'S TERRACE	FACILITY NUMBER: 107200907
	VISIT DATE: 06/22/2021

NARRATIVE

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Facility tour continued to the Family room located in the back of the facility. LPA observed 10 holes in the wall of the family room. Holes ranged from approximately 2 inches to 4 inches in diameter. Per Caregiver, the holes were there due to "behaviors".

LPA checked residents' medication. Facility has a 30 day supply of medications. Facility does not have a 30 day supply of PPE at this facility during this inspection.

LPA will return on a later date to conduct an Annual Continuation to review facility records.

Based on today's inspection, deficiencies are being cited in accordance with the California Code of Regulations, Title 22, see attached LIC809D.

An exit interview was conducted with Administrator via telephone. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: EDDIE'S TERRACE	FACILITY NUMBER: 107200907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087 (g)

80087 Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 when LPA observed 1 bottle of bleach under the kichen sink accessible to 4 out of 4 clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2021
	Plan of Correction
1 2 3 4	Caregiver removed the bottle of bleach and placed the bottle in a locked cabinet. Licensee stated that staff will be trainied on the requirements of Buildings and Grounds. Evidence of the training will be submitted to the Fresno CCL office by 07/22/2021. 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) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: EDDIE'S TERRACE	FACILITY NUMBER: 107200907
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. 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 observed 10 holes in the wall of the family room, the iron gate to be broken, dining room blinds broken and refrigerator bottom cover missing, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/22/2021
	Plan of Correction
1 2 3 4	Licensee stated that the facility will make the repairs in the areas mentioned. Evidence of the repairs will be submitted to the Fresno CCL office by 07/22/2021.

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) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4