107203215-9-29-2023-24-AS-KKAR-CW5UTM-20230929155210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107203215
Report Date: 09/29/2023
Date Signed: 09/29/2023 03:52:31 PM

Document Has Been Signed on 09/29/2023 03:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	ROYAL CARE		FACILITY NUMBER:	107203215
ADMINISTRATOR:	RIGON, RUDY G.		FACILITY TYPE:	740
ADDRESS:	2768 PURVIS AVE.		TELEPHONE:	(559) 324-8792
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 3	DATE:	09/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Designee /Administrator Aurora Rigon		TIME COMPLETED:	04:00 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	On 9/29/2023, Licensing Program Analysts (LPAs) K. Kaur and L. Padgett arrived unannounced at the above facility to conduct an Annual Inspection. LPAs introduced selves, stated the purpose of the visit, and were allowed entry by staff Modesta Paz. Staff contacted Designee /Administrator Aurora Rigon, who arrived shortly after. LPAs conducted facility tour with staff. All pathways, entrances and exits were clear from obstruction. Fire extinguisher in Living Room room was purchased 1/25/2023. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions were observed inside or outside. At 9:06 AM LPA(s) observed unlocked medication in a cabinet in the office accessible to residents. The kitchen was observed to be clean, in good repair with necessary items and appliances. 7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. At 9:10 AM LPA(s) observed unlocked disinfecting spray, Dish soap observed under kitchen sink. LPA(s) toured laundry area, and garage and observed from 9:11 AM to 9:14 AM Antiseptic Alcohol in unlocked cabinet above washing machine in laundry room and laundry detergent, bleach, and used syringes in unlocked garage. Used insulin sharps are kept in emptied laundry detergent/softener container, and were not labeled as Biohazardous Waste or Sharps Waste. Common areas were properly furnished and well-lit throughout. Facility has 3 residents who are at a day program. The dining room is equipped with a table and chairs, the living room is equipped with adequate sofas and chairs for seating. LPAs observed grab bars installed by toilet and in shower and non-skid mats in place. Residents' bedrooms were observed to be adequately furnished with bed, dresser, chair, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in the hallway closet. Continued to Next page...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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 09/29/2023 03:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 areas; unlocked disinfecting spray, Dish soap observed under kitchen sink. Antiseptic Alcohol observed in unlocked cabinet above washing machines. Laundry detergent, bleach, and used syringes observed in unlocked garage which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licnesee to remove items and place in locked area. License to ensure items remain locked in the future. Staff removed items and placed them in locked area during tour. POC cleared during visit.

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 medication audit of three individuals that revealed medication that was noted given was not which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licnesee to submit a Statement of intent to complete medication audit for all residents and provide in-service training to staff on correct administration of medication and documentation. Licnesee to ensure future spot checks to avoid medication issues.

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: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2023 03:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 in 1 out of 1 areas where LPA(s) observed unlocked backup medication in a cabinet in the office which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licnesee to remove items and place in locked area. License to ensure items remain locked in the future.

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: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 09/29/2023 03:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(2)

Maintenance and Operation

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. 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 in 1 out of 1; used insulin sharps are kept in emptied laundry detergent/softener container, but were not labeled as BIOHAZARDOUS WASTE or SHARPS WASTE. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2023
	Plan of Correction
1 2 3 4	Licnesee to utilize the Biohazard waste container observed in the garage or label the container used with correct signage.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 staff files; review showed no forms available at the facility for Licensee except for Administrator License which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee to update all Staff files to reflect the necessary required documentation by due 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: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROYAL CARE	FACILITY NUMBER: 107203215
	VISIT DATE: 09/29/2023

NARRATIVE

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At 10:53am LPA(s) tested water: 116.7F in hallway, 114.4F in bedroom 4. Carbon monoxide and smoke alarm detectors installed and operational. Adequate outside space for rest and recreational. The backyard gate is self-closing and self-latching.

At 12:23 PM LPA(s) did not observe forms available at the facility for Licensee except for Administrator License. Staff files were reviewed for good health and first aid/CPR. Resident's records contained signed Admission Agreement, Physicians Report, and I.D Emergency Information. At 1:46 PM LPAs reviewed medication, Centrally Stored List and MAR(s) for Resident 1 (R1) which showed two extra pills in package which should have already been administered per MAR(s) that were not.

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 10/06/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with
appeal rights was provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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