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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201840
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:58:43 PM

Document Has Been Signed on 04/06/2022 02:58 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:MARIAN HOMES 3FACILITY NUMBER:
107201840
ADMINISTRATOR:JANARDHAN NAGARAJFACILITY TYPE:
740
ADDRESS:3238 JASMINE AVENUETELEPHONE:
(559) 347-9900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Administrator Sundari Susan Kendakur TIME COMPLETED:
02:45 PM
NARRATIVE
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On 04/06/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with Ricky Padual. LPA conduct tour of facility with caregiver. Administrator Sundari Kendakur (Susan) was called and arrived shortly during tour. Six residents were present during the inspection.

Upon entry facility staffs was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing and cough etiquette postings were observed. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 5/7/22.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and 1 shared resident’s bed to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all bathroom sinks. LPA observed 30-day PPE supplies. Cleaning supplies were stored and locked in cabinet in the garage. LPA and Administrator observed a staff pull out bed in laundry room. The exterior tour was conducted. Side gate was self-closing and self-latching. Staffs records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information.

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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 4/12/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610E, Lic 9020, control of property, and current liability insurance. LPA received copy of Lic 808 and updated Administrator Certificate during facility inspection. Administrator was informed that as COVID-19 precautionary measure, this report and appeal rights will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 04/06/2022 02:58 PM - It Cannot Be Edited


Created By: Mai Yang On 04/06/2022 at 01:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: MARIAN HOMES 3
FACILITY NUMBER: 107201840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 (a) Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA and Administrator observed a pull-out bed in locked laundry room. Administrator confirmed S1 is a live-in staff. LPA and Administrator observed S1 personally belongings in a locked cabinet in the laundry room. S1 stated S1 have been sleeping in laundry room since July 2021 as a live-in staff. Staffs confirmed S1 have been sleeping in laundry room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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Administrator shall remove S1 personally belongings and pull out bed from locked laundry room. Administrator will submit a plan indicating live-in staff will not be sleeping in laundry room. Plan shall include any live-in staff will be reside in designated staff room.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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