107206335-8-29-2023-24-AS-KKAR-CV6TQQ-20230829145619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206335
Report Date: 08/29/2023
Date Signed: 08/29/2023 02:58:17 PM

Document Has Been Signed on 08/29/2023 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	ROYAL BOARD AND CARE FOR ELDERLY		FACILITY NUMBER:	107206335
ADMINISTRATOR:	RIGON, RUDY		FACILITY TYPE:	740
ADDRESS:	3407 N. FRESNO		TELEPHONE:	(559) 903-6846
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	6	CENSUS: 4	DATE:	08/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Aurora Rigon		TIME COMPLETED:	03:15 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 8/29/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Norma Moral. Licensee/Administrator Aurora Rigon was contacted and arrived a short while later. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions were observed inside or outside. Common areas were properly furnished and well-lit throughout. Facility has 4 residents of which 3 are at day program, one was at the facility and left a short while later. The dining room is equipped with a table and chairs, living room is equipped with adequate sofas and recliners for seating. 7-day supply of non-perishable foods and a 2-day supply of perishable foods observed. At 9:23 AM LPA observed several expired canned food items. Knives were locked in the kitchen cabinet. At 9:45 AM, unlocked Bleach and Chemical supplies were observed in the cabinet under the kitchen sink. Medications observed locked in the kitchen cabinets next to garage. LPA observed additional bleach, cleaning solutions, and disinfectants unlocked in the garage. Fire extinguisher in kitchen was purchased 1/25/2023. At 10:23 AM LPA observed shower to be without grab bars. LPA observed grab bars installed by toilet and non-skid mats in place. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available in hallway closet. Hot water temperature measured at 113.5 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Adequate outside space for rest and recreational. Backyard gate is self-closing and self-latching. Continued on LIC809C...

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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 08/29/2023 02:58 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 BOARD AND CARE FOR ELDERLY	FACILITY NUMBER: 107206335
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 10 canned foods were expired which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	Licensee to remove all canned foods and review if any items need to be disposed of based on expiration dates. Licnesee to ensure future review of canned foods in a timely manner.

Type A

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 1 out of 4 Resident's Medication was not included on Centrally Stored Medication list (CSMDR) which poses an potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2023
	Plan of Correction
1 2 3 4	Licnesee to complete a centrally stored list (CSMDR) for R3 and submit a copy to CCLD by due date and ensure all future medications are documented in Log at time of delivery to facility.

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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 02:58 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 BOARD AND CARE FOR ELDERLY	FACILITY NUMBER: 107206335
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 1 out of 4 resident's Medical assessment was not completed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2023
	Plan of Correction
1 2 3 4	Licnesee to schedule a doctor's appointment to complete a Physician’s Report (LIC 602) and submit a copy to CCLD by due date.

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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2023 02:58 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 BOARD AND CARE FOR ELDERLY	FACILITY NUMBER: 107206335
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(b)(1)

87458 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 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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 4 residents were observed to be missing TB Test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2023
	Plan of Correction
1 2 3 4	Licensee to submit a statement of intent to schedule a doctor’s appointment to complete TB testing for residents that are without and submit of results after completion of.

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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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 BOARD AND CARE FOR ELDERLY	FACILITY NUMBER: 107206335
	VISIT DATE: 08/29/2023

NARRATIVE

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At 12:10 PM LPA observed Resident’s (R1) file to be missing Physicians Report (LIC602). LPA observed two resident's (R1) and (R2) file to be missing a TB Test. LPA observed all other resident documents on file. LPA reviewed residents’ medication, MARS and Centrally Stored Medication list (CSMDR) and observed one resident’s medication was not logged. Staff files were reviewed for good health and first aid/CPR. It was verified that there are at least one staff on duty who is CPR certified.

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 9/12/2023: 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: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC809 (FAS) - (06/04)

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