107206884-3-13-2024-24-AS-AWAN-D3BSVP-20240313141304

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206884
Report Date: 03/13/2024
Date Signed: 03/13/2024 02:13:18 PM

Document Has Been Signed on 03/13/2024 02:13 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: 6	DATE:	03/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee, Paulette Holland		TIME COMPLETED:	02:25 PM

NARRATIVE

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On 03/13/2024, 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. Licensee Paulette Holland arrived shotly after LPA. LPA met with Licensee.

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. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 112.6 degrees F in the shared bedroom and 113.2 degrees F in the hallway bathroom.. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 12/08/2023. Smoke detectors and carbon monoxide detector observed operational during today’s inspection. Last fire drill conducted on 01/31/2024.

LPA reviewed staff and client records. Upon review of resident records, LPA found that R2 and R5 did not have an updated physician's report. LPA reviewed medication records and found that the facility administered medication outside the parameters of the prescription instructions for R2. LPA reviewed staff records and found that staff records did not have updated training.

CONTINUED TO LIC809-C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

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: ATTENTIVE SENIOR CARE, LLC	FACILITY NUMBER: 107206884
	VISIT DATE: 03/13/2024

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

LPA is requesting the following documents be submitted to the Fresno CCL office by 03/27/2024: 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.

Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Licensee, Paullette Holland, whose signature on this form confirms receipt with this document.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2024 02:13 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: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when facility staff administered medication outside the parameters of the prescription instructions for R2, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to ensure that all medication is administered within the parameters of the presciption instructions. The statement should include the facility plan to review section 87465 and train staff on section 87465. Training topics and attendance should be submitted to the Fresno CCL office by 04/01/2024.

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) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2024 02:13 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: 03/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when 5 out of 5 staff did not have updated training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to ensure all staff recieve an additional 20 hours of training annually.

Type B

Section Cited

CCR

87465(a)(1)

Incidental Medical and Dental Care Services

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when 6 out of 6 residents in care did not have an updated care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to develop a needs and services/care plan for 6 out of 6 residents in care and submit a copy of the care plans to the Fresno CCL office 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 Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024

LIC809 (FAS) - (06/04)

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