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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 10/07/2022
Date Signed: 10/07/2022 11:23:27 AM


Document Has Been Signed on 10/07/2022 11:23 AM - 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:NAN'S TLC HOMEFACILITY NUMBER:
107201038
ADMINISTRATOR:NEWELL-PARANGALAN, LUZFACILITY TYPE:
740
ADDRESS:6643 N. MAROA AVENUETELEPHONE:
(559) 439-2465
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY:6CENSUS: 3DATE:
10/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Licensee Larry Newell
Licensee/Administrator Luz Newell-Parangalan		TIME COMPLETED:
11:45 AM
NARRATIVE
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On 10/7/22 at 8:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management inspection. LPA explained reason for inspection and was granted entry by staff. Licensee Larry Newell and Licensee/Administrator Luz Newell-Parangalan arrived an hour later.

LPA returned to inspect the facility for correction of deficiencies CCR 87303(a) and 87307(d)(6) issued during an annual inspection on 8/12/22.

LPA observed both baby gates were removed. LPA observed hallway and master bathroom tile shower walls and floors cleaned, sliding screen doors for both master bedroom and living room replaced, pull chain installed for exterior fire exit gate, and excess electric cords in dining room were secured.

The following deficiencies were observed:
1. S1 did not have a completed transfer of criminal record clearance. S1 was present and working. S1 has been working in the facility since 9/20/22.
2. Blender blade still in blender on counter and one steak knife observed in kitchen sink and accessible.
3. Excess furniture, medical equipment, and miscellaneous items observed stored in area outside on the north side of the facility and also in the garage.

Deficiencies are being cited based on LPA observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. A civil penalty is being assessed in the amount of $100 per day, for a maximum of 5 days, for a total of $500. See LIC421BG for more details.

Exit interview conducted and Plan of Corrections were reviewed and developed with Administrator Luz Newell. A copy of this report and appeal rights were given to Administrator Luz Newell, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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 3


Document Has Been Signed on 10/07/2022 11:23 AM - 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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S1 did not have a completed transfer of criminal record clearance, S1 was present and working, S1 has been working in the facility since 9/20/22, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
10/07/2022
Section Cited

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87309 Storage Space (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:

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Blender blade observed still in blender on counter and one steak knife observed in kitchen sink and accessible, which poses an immediate safety or personal rights risk to residents in care.
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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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/07/2022 11:23 AM - 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: NAN'S TLC HOME
FACILITY NUMBER: 107201038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited

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87303 Maintenance and Operation (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:
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Excess furniture, medical equipment, and miscellaneous items observed stored in area outside on the north side of the facility and also in the garage, which poses a potential health, safety, or personal rights risk to residents in care.
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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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3