Community Care Licensing

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022

Document Has Been Signed on 08/12/2022 05:52 PM - It Cannot Be Edited

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in. LPA observed a rusted shovel outside by fire exit gate; a shovel inside garage by side exit door; a steak knife and a pair of scissors on kitchen counter; hall closet where toilet cleaner, a can of Comet cleaner, a bottle of cleaner, and a can of disinfecting spray was unlocked and accessible; a bottle of Pine Sol cleaner, spray bottle of cleaner, bottle of toilet cleaner, and can of tung oil finish were observed accessible and sitting on top of washing machine in laundry area that was accessible; and an open can of Comet cleaner, spray bottle of cleaner, large bottle of weed killer, bottle of stain odor remover, and a bottle of charcoal lighter fluid was observed accessible in garage, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator removed all items stated above into the locked hall closet or locked garage storage area during the inspection. POC cleared during inspection.

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interview, the licensee did not comply with the section cited above. LPA observed six bottles of prescribed medications accessible on top of kitchen counter, which poses an immediate health, safety, or personal rishts risk to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator removed all medication bottles to the locked centrally stored medication cabinet. POC cleared during the inspection.

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022

Document Has Been Signed on 08/12/2022 05:52 PM - It Cannot Be Edited

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not comply with the section cited above. LPA observed hallway and master bathroom tile shower walls and floors with mold and soap scum, sliding screen doors for both master bedroom and living room observed in disrepair and not sliding with ease, molded lemons and tomatoes observed in bottom drawer in refrigerator, fire exit gate observed with stiff metal wire as pull chain, excess electric cords in dining room strewn about in fireplace corner, and excess furniture, medical equipment, mattresses, and miscellaneous items observed in back patio and in garage, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Administrator will clean hall and master bathroom tile shower walls and floors, replace sliding screen doors for both master bedroom and living room to open/close with ease, fire exit gate pull chain replaced, excess electric cords in dining room organized and tied together, and excess furniture, medical equipment, mattresses and miscellaneous items in back patio and in garage are to be removed from the facility by the POC due date. Administrator removed and disposed of the molded lemons and tomatoes from the refrigerator during the inspection. LPA will return for a POC visit.

Type B

Section Cited

CCR

87307(d)(6)

(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
1 2 3 4	Based on observations, the licensee did not comply with the section cited above. Baby gate is installed between dining room and kitchen and passageway between foyer and kitchen. Treadmill observed stored in passageway between foyer and kitchen, all which poses a potential safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	Administrator will remove both baby gates and treadmill from the facility by POC due date. LPA will return for a POC visit.

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022

Document Has Been Signed on 08/12/2022 05:52 PM - It Cannot Be Edited

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Type B

Section Cited

CCR

87211(a)(1)

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not comply with the section cited above. On 6/28/22, all four residents tested positive for COVID-19 and the Administrator did not submit an incident report to CCL, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Administrator will submit proof of an in-service training roster for Administrator for the training topic of 87211 Reporting Requirements to CCL by POC due date. LPA provided a copy of CCR 87211 Reporting Requirements to Administrator during the inspection.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022

Document Has Been Signed on 08/12/2022 05:52 PM - It Cannot Be Edited

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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. All fire extinguishers in the facility, total of 2, were last serviced on 9/12/2020, which poses an immediate health or safety risk to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator will submit proof of newly purchased fire extinguishers to CCL by POC due date.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
	VISIT DATE: 08/12/2022

FACILITY NAME: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Type A

Section Cited

CCR

87555(b)(25)

(b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above. LPA observed an open can of Comet cleaner, two large bottles of Pine Sol cleaner, a bottle of charcoal lighter fluid, and a spray bottle of cleaner stored in open area below a small table in garage where several bags of spaghetti, a medium sized plastic container filled with white rice, and several canned food items were kept, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2022
	Plan of Correction
1 2 3 4	Administrator removed all items stated above into locked storage area in garage during the inspection. POC cleared during the inspection.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Melinda Hoffmann TELEPHONE: (559) 341-3274 LICENSING EVALUATOR NAME: Malia Thao TELEPHONE: (559) 470-9001 LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022