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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206664
Report Date: 08/18/2021
Date Signed: 08/18/2021 04:01:19 PM

Document Has Been Signed on 08/18/2021 04:01 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:BURRUS ADULT RESIDENTIALFACILITY NUMBER:
107206664
ADMINISTRATOR:BURRUS, LINDAFACILITY TYPE:
735
ADDRESS:157 N. ARMSTRONGTELEPHONE:
(559) 321-8737
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 4DATE:
08/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Administrator, Linda BurrusTIME COMPLETED:
09:45 AM
NARRATIVE
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On 08/18/2021, Licensing Program Analysts (LPAs) arrived unannounced to conduct a Case Management - Deficiencies inspection. LPAs introduced selves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Linda Burrus.

The purpose of today's visit is to follow up on an incident reported to the Fresno CCL office. It was reported that R1 did not receive 1 out of 3 medications as prescribed. Per Administrator, R1 self discontinued taking the medication prior to moving into the facility. Administrator was not aware that R1 had the medication in R1's possession. It was also reported that R1's medications were not locked and inaccessible to residents in care. Per Administrator, R1 is high functioning and was able to administer R1's own medications. Administrator has secured medications in a locked cabinet inaccessible to residents in care.

Based on today's visit, a deficiency is being cited in the area evaluated and listed on the 809-D according to California Code of Regulations, Title 22, Division 6.

An exit interview was conducted. A Plan of Correction was developed and reviewed with Administrator. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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 08/18/2021 04:01 PM - It Cannot Be Edited


Created By: Alexandria Walton On 08/18/2021 at 09:17 AM
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: BURRUS ADULT RESIDENTIAL
FACILITY NUMBER: 107206664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
Section Cited
CCR
85075(b)

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85075 Health Related Service(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.This requirement was not met as evidenced by:
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Licensee agreed to submit a plan detailing steps the facility will take to ensure R1 has a plan developed and implemented to ensure R1 receives assistance in administering medications. To the Fresno CCL office by 8/19/2021.
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Based on interviews conducted and records review, the facility did not develop and implement a plan to assist R1 with medications when R1's medications were in R1's possession accessible to residents in care and when the faciltiy was not aware that R1 self discontinued a prescribed medication prior to moving into the facility. This poses an immediate health and safety risk to persons in care.
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Licensee stated that staff will be trainied on the requirements of Health Related Services. Evidence of training topics and attendance will be submitted to the Fresno CCL office by 08/20/2021.

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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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