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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206823
Report Date: 06/10/2024
Date Signed: 06/10/2024 03:07:46 PM


Document Has Been Signed on 06/10/2024 03:07 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:MCWEALTH CARE INC.FACILITY NUMBER:
107206823
ADMINISTRATOR:JOSHUA MCWEALTHFACILITY TYPE:
735
ADDRESS:6167 N. CORNELIA AVETELEPHONE:
(559) 374-5476
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:4CENSUS: 3DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:April GaylordTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Managers/Facility Designees, April Gaylord (S1) and Ester Jackson (S2) arrived shortly after. Administrator Certification was verified during the inspection. Certification Number 700813735 Expires 5/17/2024.

During this visit, LPA toured the facility inside & out. Resident rooms contained required furnishings and lighting. The resident bathroom was clean and in good repair with faucets delivering hot water at 115 degrees. LPA observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in a kitchen cabinet. The First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced 5/17/24 by Midstate Fire Co. Smoke and Carbon Monoxide detectors were tested and found to be in working condition. LPA conducted staff and resident file reviews.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Building and Grounds



An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 6/17/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Emergency Disaster Plan (LIC610D (2021)), Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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Document Has Been Signed on 06/10/2024 03:07 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: MCWEALTH CARE INC.
FACILITY NUMBER: 107206823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024

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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed: damaged walls, repaired walls that require paint, dirty and scuffed doors throughout the facility including front door, food on wall at dining table, damaged/unoperable ceiling fan on back patio.
POC Due Date: 06/24/2024
Plan of Correction
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Administrator (AD) has agreed to provide inservice with all staff on the procedures of housekeeping in the areas of: Cleaning doors and walls throughoiut the home. A copy of the inservice with names and signatures will be provided. Additionally, walls will be repaired and painted and the outdoor ceiling fan with damageed blades and no light cover will be removed. Inservice sheet and pictures of corrections will be submitted by POC date.
Type B
Section Cited
CCR
85088(c)(1)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).

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, which poses/posed a potential health, safety or personal rights risk to persons in care. R1 matress cover is torn in multiple places, the matress is soiled, the bed is not placed correctly on the metal frame causing a safety risk.
POC Due Date: 06/24/2024
Plan of Correction
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AD has agreed to replace the bed frame, matress and matress cover. Additional covers will be purchased and available it the new one is torn. Pictures of the above replaced items will be submitted to CCL by POC date.
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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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