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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204025
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:01:59 PM

Document Has Been Signed on 09/30/2024 01:01 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:G & SFACILITY NUMBER:
107204025
ADMINISTRATOR/
DIRECTOR:		STREETS, SENAFACILITY TYPE:
735
ADDRESS:4288 W. MICHIGANTELEPHONE:
(559) 275-3815
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 4DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Sena StreetsTIME VISIT/
INSPECTION COMPLETED:
01:15 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 Administrator (AD) Sena Streets.

During this visit, LPA toured the facility inside & out. Resident rooms and common areas were clean, in good repair and contained required equipment, furnishings and lighting. LPA observed required items in bathrooms with hot water measuring 108 degrees in a resident bathroom. LPA observed hygiene items, towels, extra bedding, and linens which were stored and available for use. 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 were locked are stored separate from food. Medications are centrally stored in a locked closet. Doors and passageways are unobstructed throughout the facility including outdoors. A First aid kit contained required items. Facility has multiple visitation and common areas available. LPA walked the outdoor areas to find the grounds well-kept with walkways and sitting areas. A fire extinguisher was serviced 8/12/24. Smoke and carbon monoxide detectors were observed and tested. LPA conducted resident and staff file reviews, P&I and medication audits. Emergency Disaster and Infection Control requirements 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: Health-Related Services, and Infection Control Requirements. An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 10/14/24: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan LIC610D (12/22), Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage, Infection Control Plan (LIC9282).
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 09/30/2024 01:01 PM - It Cannot Be Edited


Created By: Katie Brown On 09/30/2024 at 12:25 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: G & S
FACILITY NUMBER: 107204025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

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 Ativan 0.5mg medication card was found to have 2 additional tabs. These findings are based on facility documented start date and medication count.
POC Due Date: 10/01/2024
Plan of Correction
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AD has agreed to submit a written statement to CCL which will include the staff in-service plan. The in-service plan will address staff's role to ensure medications are assisted with accurately, PRN documentation procedure changes, and that the centrally stored medication log is maintained in resident files. This training will be completed within 10 days and a copy of the in-service sign in sheet will be submitted to CCLD. The written statement will be submitted by poc date.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 09/30/2024 01:01 PM - It Cannot Be Edited


Created By: Katie Brown On 09/30/2024 at 12:25 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: G & S
FACILITY NUMBER: 107204025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)(1)(C)2
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022.  (1) The Infection Control Plan shall include all of the following:  (C) An Infection Control Training Plan.  2. Ongoing training requirements for all facility staff shall be addressed by the plan, with training to be provided by the Infection Control Lead.

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.
POC Due Date: 10/14/2024
Plan of Correction
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AD has agreed to provide Infecton Control Training to all staff. AD agrees to obtain Infection Control Lead certification. A copy of the staff in-service training which includes a summary on the in service will be submitted to CCLD by poc date.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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