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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206784
Report Date: 02/20/2024
Date Signed: 02/20/2024 02:48:17 PM

Document Has Been Signed on 02/20/2024 02:48 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:CHARLOTTE'S PLACE, INC.FACILITY NUMBER:
107206784
ADMINISTRATOR:GRAY, CHARLOTTEFACILITY TYPE:
735
ADDRESS:4262 N. GLENN AVETELEPHONE:
(559) 478-4403
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:House Manager, Maria Galindo and Administrator, Charlotte GrayTIME COMPLETED:
03:20 PM
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On 02/20/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff contacted Administrator, Charlotte Gray via telephone. Administrator was unable to attend the beginning of the inspection, due to a previously scheduled medical appointment. LPA received verbal permission to meet with House Manager, Maria Galindo. Administrator, Charlotte Gray arrived during the inspection.

During the inspection the facility appeared clean and at a comfortable temperature. Common areas were furnished and had adequate seating and lighting available. Resident bedrooms appeared clean and had required furnishings. LPA observed the light bulbs in the ceiling fan in bedroom 3 need to be replaced. Residents bathrooms appeared clean, water temperature measured at 122 degrees F in the bathroom (B1) in bedroom 2 and 121.6 degrees F in the hallway bathroom (B2). LPA observed that the drain in the sink in B1 is in need of repair. LPA observed the towel bars in B2 in need of replacement/repair. Facility kitchen appeared to be clean and safe for food preparation. Food supply checked. LPA observed two bottles of disinfectant stored in the facility pantry. LPA observed that the floor tiles in the kitchen need to be repaired and the light fixture above the kitchen sink needs to be replaced.

Exterior tour conducted, all exits open and free of obstructions on today’s visit. LPA observed the side walkway and gutters needing to be cleaned. Fire extinguisher is current with a service date of 06/19/2023. Smoke detectors and carbon monoxide detector observed to operational. Last fire drill conducted on 01/15/2024. Cleaning supplies observed to be locked in a cabinet. LPA reviewed client and staff files. Upon review of files, LPA found that the staff did not have health screens on file. Medications observed to be locked and administered as prescribed.

CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784
VISIT DATE: 02/20/2024
NARRATIVE
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LPA is requesting the following documents be submitted to the Fresno CCL office by 03/05/2024: 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 (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) Surety Bond, Infection Control Plan.

Deficiencies are being issued on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Charlotte Gray, whose signature on this form confirms receipt of this document.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 02/20/2024 02:48 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/20/2024 at 02:00 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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when hot water measured at 122.0 degrees F and 121.6 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section is met, to the Fresno CCL office. The plan should include the facility's plan to monitor water temperature for 1 week and submit the water log to the Fresno CCL office by 02/28/2024
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 02/20/2024 02:48 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/20/2024 at 02:00 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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when Tile floors in the facility kitchem, the light fixture above the kitchen sink, the drain in the sink in the bathroom in bedroom 2, towel bars in hallway bathroom, light bulbs in bedroom 3, moss on the back side walk needs to be removed and the gutters in the facility need to be clean were in need of repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2024
Plan of Correction
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Licensee agrees to make the repairs or replace the items and/or submit a plan to make the repairs to include the date the repairs will be made to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 in 6 out of 7 staff did not have a health screen on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2024
Plan of Correction
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Licensee agrees to submit a plan detailing the steps the facility will take to ensure the requirements for section 80066 are met to the Fresno CCL by the POC due date. The plan should include the date when all staff have been screened for health.
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: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 02/20/2024 02:48 PM - It Cannot Be Edited


Created By: Alexandria Walton On 02/20/2024 at 02:00 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: CHARLOTTE'S PLACE, INC.
FACILITY NUMBER: 107206784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when two bottles of cleaning substances were observed in the facility pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Licensee removed the bottles from the pantry and placed the bottles in a locked cabinet inacessible to residents in care. POC CLEARED during inspection.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024


LIC809 (FAS) - (06/04)
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