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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206884
Report Date: 03/24/2023
Date Signed: 03/24/2023 01:46:43 PM


Document Has Been Signed on 03/24/2023 01:46 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, LLCFACILITY NUMBER:
107206884
ADMINISTRATOR:HOLLAND, LAWRENCEFACILITY TYPE:
740
ADDRESS:36 E. TUOLUMNE STREETTELEPHONE:
(559) 449-3566
CITY:FRESNOSTATE: CAZIP CODE:
93706
CAPACITY:6CENSUS: 6DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Licensee, Paulette HollandTIME COMPLETED:
02:00 PM
NARRATIVE
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On 03/24/2023, 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 Licensee, Paulette Holland, via telephone who arrived a short time later. LPA disclosed the purpose of the visit with the Licensee Paulette Holland.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. LPA observed the water pressure for the sink in bathroom two to be low preventing an adequate flow of hot water. Hot water measured at 128.7 degrees F. in bathroom 1. Kitchen toured, appeared clean. LPA observed an adequate supply of food. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 12/13/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. All cleaning supplies are locked in secured under kitchen sink.

LPA reviewed staff and client records. Medications reviewed and observed to have original labels. Upon review of records, LPA found that facility staff did not administer medications to 2 out of 6 residents due to medications needing to be refilled. LPA observed the first aid kit was not up to date.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/07/2023: 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. CONTINUED TO 809C.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 03/24/2023 01:46 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: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

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 when 2 out of 6 residents did not receive medications due to needing refills, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2023
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 are met to the Fresno CCL office by the POC due date.
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 HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 03/24/2023
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Deficiencies are being issued in accordance to California Code of Regulations, Tittle 22, Division 6 on the attached 809D.

Exit interview conducted and a plan of correction was reviewed and developed with Licensee. A copy of this report and appeal rights were discussed and provided to Licensee, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/24/2023 01:46 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: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree 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 1 out of 2 bathroom delivered hot water measuring 128.7 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2023
Plan of Correction
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Licensee agrees to adjust the water heater to deliver hot water measured between 105 - 120 degrees F. Licensee agreed to document the hot water temperature for 7 days to ensure hot water is within range of 105 - 120 degrees F. Documentation will be submitted to the Fresno CCL office.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, 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 1 out 2 bathrooms sinks was need in repair in order to deliver hot water to residents for personal care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2023
Plan of Correction
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Licensee agreed to have the sink repaired by contacting a plumber to correct the water pressure by the POC due 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4