107201038-8-9-2024-24-AS-AWAN-D7YP2Z-20240809105648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 08/09/2024
Date Signed: 08/09/2024 10:56:56 AM

Document Has Been Signed on 08/09/2024 10:56 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 HOME		FACILITY NUMBER:	107201038
ADMINISTRATOR:	NEWELL-PARANGALAN, LUZ		FACILITY TYPE:	740
ADDRESS:	6643 N. MAROA AVENUE		TELEPHONE:	(559) 439-2465
CITY:	FRESNO	STATE: CA	ZIP CODE:	93704
CAPACITY:	6	CENSUS: 6	DATE:	08/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Administrator, Luz Newell-Parangalan		TIME COMPLETED:	11:00 AM

NARRATIVE

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On 08/09/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Facility staff contacted Licensee via telephone. Administrator, Luz Newell-Parangalan and Licensee Larry Newwell arrived as short time later, LPA met with Administrator.

LPA conducted a tour inside and outside of the facility. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed full bed rails equipped on residents bed. Administrator did not have a physician's order for the bed rails. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 113.0 degree F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 09/29/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 06/22/2024. LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed.

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Luz Newell, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/23/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E ) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond**

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 08/09/2024 10:56 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: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 full bed rails were observed to be equipped on a resident's bed without a physician's order, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Licensee removed bed rails for resident's bed. POC cleared during inspection.

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: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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