107201038-7-19-2023-24-AS-AWAN-CTVRCU-20230719125454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201038
Report Date: 07/19/2023
Date Signed: 07/19/2023 12:55:02 PM

Document Has Been Signed on 07/19/2023 12:55 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:	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: 4	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Licensee, Larry Newell		TIME COMPLETED:	01:15 PM

NARRATIVE

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On 07/19/2023, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry to the facility by facility staff. Facility staff contacted Licensee, Larry Newell, who arrived a short time later.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. LPA observed furniture blocking the exit in the living room near the main entrance. Resident rooms appeared clean and had required furnishings. LPA observed chair blocking the exit in bedroom 3, facility staff moved the chair during the inspection. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and shower areas, non-skid mats were observed. LPA observed a bottle of disinfectant under the sink in bathroom 2, facility staff removed the bottle and placed the bottle in a locked cabinet.. Hot water measured at 112.4 degrees F in bathroom 1 and 109.7 degrees F in bathroom 2. Kitchen toured, appeared clean. Upon entry to the facility, LPA observed multiple knives on top of container in the kitchen, facility staff removed the knives and placed the knives in a locked cabinet. LPA observed an adequate food supply. Exterior tour conducted, LPA observed various equipment on the patio blocking an exit leading to the living room near the main entrance. Side gate was observed to be self-latching.

Fire extinguisher serviced on 08/15/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted in April 2022.

LPA reviewed resident records. LPA will return at a later date to review medications and personnel files.

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

Exit interview conducted with Licensee. A copy of this report and appeal rights were discussed and left with Licensee, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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 07/19/2023 12:55 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: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(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 observation, the licensee did not comply with the section cited above, when LPA observed various equipment to be blocking an exit in the backyard and a chair furniture blocking the exit in the living room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/20/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to clear the passageway obstructions to the Fresno CCL office by the POC due date. LPA will follow up with the Licensee/Administrator by 8/4/2023 to ensure the various obstructions are no longer blocking exits/passageways.

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: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/19/2023 12:55 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: NAN'S TLC HOME	FACILITY NUMBER: 107201038
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above when knives were observed on a container in the kitchen accessible to residents in care and a bottle of disinfectant was observed under sink the bathroom which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Facility staff removed the knives and bottle of disinfectant and placed the items in a locked cabinet inaccessible to residents in care 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

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: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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