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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201156
Report Date: 10/17/2022
Date Signed: 10/17/2022 07:43:49 PM


Document Has Been Signed on 10/17/2022 07:43 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:FAIRWINDS - WOODWARD PARKFACILITY NUMBER:
107201156
ADMINISTRATOR:VALERO, DESIREEFACILITY TYPE:
740
ADDRESS:9525 N FT WASHINGTON RDTELEPHONE:
(559) 434-6444
CITY:FRESNOSTATE: CAZIP CODE:
93730
CAPACITY:270CENSUS: 212DATE:
10/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Desiree Valero, AdministratorTIME COMPLETED:
08:00 PM
NARRATIVE
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On 10/17/22 at 3:00 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - deficiencies inspection. LPA explained the reason for inspection and met with Administrator Desiree Valero.

LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered.

CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22. The facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22.

Deficiencies are being cited based on LPA's observations, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A civil penalty of $250 is being assessed for a repeat violation of CCR 87211(a)(1)(D) which was first issued on 6/2/22. See LIC421FC for more details.

Exit interview conducted and Plan of Corrections were developed and reviewed with Administrator Desiree Valero. A copy of this report and appeal rights were given to Administrator, 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: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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 10/17/2022 07:43 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: FAIRWINDS - WOODWARD PARK
FACILITY NUMBER: 107201156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2022
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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LPA found that on 6/5/22, R1's medication Ciprofloxacin 500 mg Tabs (Take 1 tablet orally two times daily) were given three times at the times of 8:10 AM, 5:37 PM, and 7:22 PM. On 6/7/22, the facility received new Amlodipine 5mg (Take 1 tablet orally daily) from the pharmacy some time in the evening of the day and S1 administered a dose the same evening after finding that the new medication was received and in the med room. The facility had already given the medication Amlodipine 10mg (Take 1 tablet orally daily) earlier that day at 6:30 AM. LPA found that the facility did not receive the doctor's order for the change in dosage for the medication until 6/8/22. LPA found that R1's medication bubble pack Amlodipine 10mg that was filled on 4/21/22 to be started 5/1/22 and the bubble pack Amlodipine 10 mg that was filled on 5/20/22 to be started 5/29/22 was recorded on the Centrally Stored Medication sheet and in the facility's internal digital medication administration log as given, but both bubble packs were still intact and full without any doses administered. Which poses a potential health and personal rights risk to resident in care.
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Type B
10/31/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D)...(D) Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidenced by:
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CCL received a faxed incident report on 6/20/22 for an incident that occurred on 6/10/22 and the facility sent an incident report to CCL on 6/23/22 for an incident that occurred on 6/7/22, 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: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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