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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107201578
Report Date:
08/20/2024
Date Signed:
08/20/2024 03:32:34 PM
Document Has Been Signed on
08/20/2024 03:32 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:
WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER:
107201578
ADMINISTRATOR:
WHITTLE, CHERYL A
FACILITY TYPE:
740
ADDRESS:
4093 W. TERRACE AVENUE
TELEPHONE:
(559) 271-2152
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93722
CAPACITY:
6
CENSUS:
2
DATE:
08/20/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:17 AM
MET WITH:
Designee Laplac "Chris" Maxie
TIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Robena James. Administrator Cheryl Whittle was contacted and authorized Facility Designee Laplac "Chris" Maxie to continue the visit and sign reports.
During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring at 114 degrees. Resident hygiene supplies were observed as well as a backup supply. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are stored separate from food. Medications are centrally stored and locked. A First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed windows with screens in good repair. Doors and passageways are unobstructed throughout the facility and outside. Fire Extinguisher was serviced 2/27/24 by Jorgensen Co. LPA reviewed fire drill logs. Smoke and Carbon Monoxide detectors present and tested during the visit. LPA conducted resident and staff file reviews as well as medication audit. Required postings were observed throughout the facility. Emergency Disaster and Infection Control Plans were reviewed during the inspection.
Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Storage Space, Incidental Medical and Dental Care Services, Medical Assessment
.
An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by and Appeal Rights were provided.
SUPERVISOR'S NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 246-0610
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE:
08/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2024
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
12
Document Has Been Signed on
08/20/2024 03:32 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:
WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER:
107201578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the cleaning/disinfecting supply cabinet in the garage to be unlocked, rubbing alcohol, hydregen peroxide and scissors in an unlocked cabinet in the ofice and cleaning supplies under office sink.
POC Due Date:
08/21/2024
Plan of Correction
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All of the cleaning solutions, poisons, and other items which could pose a danger to residents were immediately secured as required and a new lock was placed on the garage cabinet. DEFICIENCY CLEARED.
Administrator (AD) has agreed to conduct staff in-service to all staff.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA conducted a medication audit. R1's Lorazapam cards for 3pm and 7pm contained additional pills based on the start date as recorded by staff. 3pm - 3 additional, 7pm - 5 additional pills. Additionally, there are multiple blank MAR dates where staff did not initial - unable to confirm if medication was given as ordered.
POC Due Date:
08/21/2024
Plan of Correction
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AD has agreed to submit a written statement which will include: plan to implement proper medication assistance procedures., Additionally, staff in-service and medication closet reorganization within 30 days. The statement will be submitted to LPA via email by POC date.
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:
Sergiy Pidgirny
TELEPHONE:
(559) 246-0610
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE:
08/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2024
LIC809
(FAS) - (06/04)
Page:
2
of
12
Document Has Been Signed on
08/20/2024 03:32 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:
WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER:
107201578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility does not maintain a PRN log which contains all elements required in documentation.
POC Due Date:
09/23/2024
Plan of Correction
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AD has agreed to implement the use of a PRN Log which meets the documentation requirements. Staff will be trained on the procedure. A complete training log including staff name and signature will be submitted as well as a copy of the new procedure and the log by POC date. The POC will be emailed to LPA.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. R1's Physician Report dated 5/2023 does not document Diabetes or R1's ability to selfn administer glucose testing with assistance. Additionally, R1 and R2's reports note MCI which required to be updated allually.
POC Due Date:
09/23/2024
Plan of Correction
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AD agrees to obtain an updated and complete Physician's Report for R1 and R2. A copy of the reports will be submitted to CCL by POC date via email.
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:
Sergiy Pidgirny
TELEPHONE:
(559) 246-0610
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE:
08/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2024
LIC809
(FAS) - (06/04)
Page:
3
of
12
Document Has Been Signed on
08/20/2024 03:32 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:
WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER:
107201578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. A current and complete Centrally Stored Medication and Destruction Log is not maintained.
POC Due Date:
09/23/2024
Plan of Correction
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AD agrees to implement the use of a Centrally Stored Medication and Destruction Log. Staff will be in-serviced on the procedure and a complete sign in sheet containing names and signatures along with a copy of the updated procedure will be submitted via email to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Sergiy Pidgirny
TELEPHONE:
(559) 246-0610
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE:
08/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2024
LIC809
(FAS) - (06/04)
Page:
11
of
12
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:
WILLIAMS-WHITTLE RESIDENTIAL CARE HOME #3
FACILITY NUMBER:
107201578
VISIT DATE:
08/20/2024
NARRATIVE
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LPA requested the following
updated
forms faxed to CCLD by 9/3/24: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610E, Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISOR'S NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 246-0610
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE:
08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2024
LIC809
(FAS) - (06/04)
Page:
12
of
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