107206609-11-29-2022-24-AS-KKAR-CLMT2L-20221129132055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206609
Report Date: 11/29/2022
Date Signed: 11/29/2022 01:22:16 PM

Document Has Been Signed on 11/29/2022 01:22 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:	GETTYSBURG CHRISTIAN HOME		FACILITY NUMBER:	107206609
ADMINISTRATOR:	DYER, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	4844 E. GETTYSBURG		TELEPHONE:	(559) 294-9080
CITY:	FRESNO	STATE: CA	ZIP CODE:	93726
CAPACITY:	18	CENSUS: 13	DATE:	11/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	Staff Gloria Guerrero		TIME COMPLETED:	12:30 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 11/29/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection -Infection Control. LPA met with staff Gloria Guerrero and stated the purpose of the visit. Administrator, Elizabeth Dyer was contacted via telephone but was unavailable to come to the facility. Permission was granted for staff to complete inspection and sign for report. Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Facility staff observed without facial coverings. Facility appeared clean with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas. Cleaning supplies were secured in the locked laundry room. LPA observed hallway closet to contain additional bedding and blankets. At 11:26 AM, LPA observed Medications secured in a locked office. LPA observed the Medication Administration Record (MARs) to be incomplete. Sharp items are kept locked in the kitchen area. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the kitchen area was last serviced on 11/2/2022 and was fully charged. Bathrooms have trash cans with lids. Hand washing posters were observed in the bathrooms by the sink. Staff records were reviewed for good health, infection control training. Resident’s files have updated emergency contact information. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Continued on next page.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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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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: GETTYSBURG CHRISTIAN HOME	FACILITY NUMBER: 107206609
	VISIT DATE: 11/29/2022

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 12/6/2022: 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 (LIC610E)

An exit interview was conducted with Staff. Report signed on-site and a copy of report will be email to Licensee.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep Kaur	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2022 01:22 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: GETTYSBURG CHRISTIAN HOME	FACILITY NUMBER: 107206609
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(2)

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was 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 when LPA observed the facility November 2022 MARs to be incomplete. LPA is unable to determine if medications were given which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	AD has agreed to provide training to all staff who assist residents with medication. Training will include the facility documentation procedure. A copy of the training In service sign in and materials used will be provided to CCLD via email or fax.

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: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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