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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206609
Report Date: 10/31/2022
Date Signed: 10/31/2022 01:53:45 PM

Document Has Been Signed on 10/31/2022 01:53 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:GETTYSBURG CHRISTIAN HOMEFACILITY NUMBER:
107206609
ADMINISTRATOR:DYER, ELIZABETHFACILITY TYPE:
740
ADDRESS:4844 E. GETTYSBURGTELEPHONE:
(559) 294-9080
CITY:FRESNOSTATE: CAZIP CODE:
93726
CAPACITY: 18CENSUS: 13DATE:
10/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Joyce TorresTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct the initial complaint visit. LPA met with facility designee/Staff (S1) Joyce Torres. LPA spoke to Administrator (AD) Elizabeth Dyer on the phone who was unable to come to the facility. AD authorized S1 to meet with LPA and sign the report.

During the facility tour, LPA observed the following:
1. Facility Medication Administration Record (MAR) is incomplete.
2. Fire Extinguishers are not properly serviced

Deficiencies are being cited in accordance with California Code of Regulations Chapter 8 on the attached LIC 9099-D.


An exit interview was conducted and Plans of Corrections were reviewed and developed. A copy of this report and Appeal Rights were discussed and left with Joyce Torres, whose signature on this form confirm receipt of these documents



SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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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Document Has Been Signed on 10/31/2022 01:53 PM - It Cannot Be Edited


Created By: Katie Brown On 10/31/2022 at 01:12 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: GETTYSBURG CHRISTIAN HOME
FACILITY NUMBER: 107206609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidenced by:
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Administrator (AD) has agreed to provide proof or invioce to CCLD that all fire extinguishers have been serviced by the due date. Proof of service can be emailed or faxed to LPA.
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Licensee did not ensure that the facility fire extinguishers are maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. LPA observed the fire extinguishers have not been serviced since 7/13/2021 and are required to be serviced annually.
This poses a potential health, safety or personal rights to persons in care.
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Type B
11/08/2022
Section Cited
CCR87465(c)(2)

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87465 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:

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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 inservice sign in and materials used will be provided to CCLD via email or fax.
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(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:

LPA observed the facility October 2022 MAR. LPA is unable to determine if medications were given. Resident names are missing from pages of the MAR.
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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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022


LIC809 (FAS) - (06/04)
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