<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202828
Report Date: 09/21/2024
Date Signed: 09/23/2024 11:43:08 AM


Document Has Been Signed on 09/23/2024 11:43 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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:A PLACE CALLED HOME RESIDENTIAL CARE 5FACILITY NUMBER:
107202828
ADMINISTRATOR:MURCHISON, COLINFACILITY TYPE:
740
ADDRESS:10736 E MENDOCINO BAYTELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 5DATE:
09/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility staff, Camile AgarinTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with facility staff Camile Agarin Continual Administrator's Certification expires 05/06/2025. There are currently 5 residents who reside at this home and there is 1 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 107 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

Resident 1 does not have a Physician's Report updated annually as required. The facility staff files are not available for Licensing to review. Resident 1's medication was not logged correctly on the Centrally Stored Medication record.

The facility does have an Emergency Disaster plan, but it is on the older version the form.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with facility staff Camile Agarin, and copy of report left at facility

SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
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 2


Document Has Been Signed on 09/23/2024 11:43 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,
, CA


FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL CARE 5
FACILITY NUMBER: 107202828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Resident 1's Physician report is more than one year old, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2024
Plan of Correction
1
2
3
4
Licensee will ensure Resident 1 has a Physician's Report updated anuually and send proof to LPA by POC date of 10/05/2024.
Type B
Section Cited
CCR
87465(a)(6)


87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:


(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:

(A) The name of the resident for whom prescribed.

(B) The name of the prescribing physician.

(C) The drug name, strength and quantity.

(D) The date filled.

(E) The prescription number and the name of the issuing pharmacy.

(F) Instructions, if any, regarding control and custody of the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above in Resident 1's medication was not logged into the Centrally Stored Medication Record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2024
Plan of Correction
1
2
3
4
Licensee will conduct medication administration training with facility staff, and submit to LPA by POC date of 10/05/2024.
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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2