107206884-4-13-2022-24-AS-AWAN-CDFQKU-20220413121454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206884
Report Date: 04/13/2022
Date Signed: 04/13/2022 12:15:06 PM

Document Has Been Signed on 04/13/2022 12:15 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:	ATTENTIVE SENIOR CARE, LLC		FACILITY NUMBER:	107206884
ADMINISTRATOR:	HOLLAND, LAWRENCE		FACILITY TYPE:	740
ADDRESS:	36 E. TUOLUMNE STREET		TELEPHONE:	(559) 449-3566
CITY:	FRESNO	STATE: CA	ZIP CODE:	93706
CAPACITY:	6	CENSUS: 5	DATE:	04/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Caregiver, Tiffany Owen and Administrator, Paulette Holland		TIME COMPLETED:	12:22 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 04/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Administrator was not present upon LPA's arrival, LPA spoke with Administrator, Lawrence Holland who gave LPA verbal permission to meet with Caregiver, Tiffany Owen. Administrator, Paulette Holland arrived a short time later. Facility has one central entry/exit. Facility tour conducted with Caregiver Owen. Social distancing is maintained in the common and dining areas. LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked, food was observed to be improperly stored. Cleaning and PPE supplies were checked. Facility has 3 shared bedrooms. Beds were observed to be at least 3 feet apart with head to toe orientation. In bedroom 1, LPA observed the fire exit to be blocked by a residents bed and a chair. Bathrooms toured. LPA did not observe hand washing signs and trash cans did have a lid. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, see attached 809D. CONTINUED TO 809C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ATTENTIVE SENIOR CARE, LLC	FACILITY NUMBER: 107206884
	VISIT DATE: 04/13/2022

NARRATIVE

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LPA is requesting the following documents be submitted to the Fresno CCL office by 04/27/2022 Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, and Mitigation Plan (LIC808).

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, Paulette Holland, whose signature on this form confirms receipt of this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/13/2022 12:15 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: ATTENTIVE SENIOR CARE, LLC	FACILITY NUMBER: 107206884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is 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 as evidenced by the fire exit in bedroom 1 blocked by a resident's bed and chair, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2022
	Plan of Correction
1 2 3 4	Licensee moved the bed and the chair from blocking the fire exit in bedroom 1. POC CLEARED during inspection.

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: Melinda Hoffmann	TELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC809 (FAS) - (06/04)

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