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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206911
Report Date: 11/08/2021
Date Signed: 11/08/2021 02:48:30 PM

Document Has Been Signed on 11/08/2021 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:CAROLINA HOMEFACILITY NUMBER:
107206911
ADMINISTRATOR:JESSICA RUEDAFACILITY TYPE:
735
ADDRESS:1086 CAROLINA AVENUETELEPHONE:
(559) 326-7758
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 4CENSUS: 4DATE:
11/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Brittany Cupps, Area Director via telephone and Thomas Moore, caregiverTIME COMPLETED:
09:20 AM
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On 11/08/21 Licensing Program Analyst (LPA), M. Yang arrived unannounced to conduct a Case Management - Deficiencies inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Thomas Moore, caregiver. Brittany Cupps, Area Director was called and unable to attend. Area Director authorized caregiver to received reports.

The purpose of the today's visit is to address a medication error. It was reported that on 10/07/21, Three residents did not receive their medications. C1 did not receive one medication: Gabapentin. C2 did not received one medication: Pantoprazole. C3 did not receive three medications: Thera-m, Omega-3, MI- Acid-Gas, and Lorazepam. The medications should have been administered at 4:00 PM on 10/06/21.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached 809D.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with Brittany Cupps, Area Director and caregiver.

As a COVID-19 precautionary measure, a copy of this report and appeal rights will be provided via email and an electronic read receipt confirms receiving these document
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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 11/08/2021 02:48 PM - It Cannot Be Edited


Created By: Mai Yang On 11/08/2021 at 08:59 AM
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: CAROLINA HOME
FACILITY NUMBER: 107206911

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
80075(b)

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80075 Health Related Services: (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidenced by:
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Licensee stated that staff was retrained Health-Related Services regulations. Licensee will submit documentation of training topics and attendance roster to the Fresno CCL office by 11/9/21.
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Based on interviews and records review, the licensee did not ensure staff administering C1, C2, and C3 medications at 4:00 PM on 10/07/20221, which poses an immediate health and safety risks to persons in care.
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Licensee shall submit a written Plan of Correction (POC) Licensee agrees to schedule staff to administer medications to ensure the requirements of Health-Related Services are met.

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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:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2021


LIC809 (FAS) - (06/04)
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