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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206929
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:58:56 PM


Document Has Been Signed on 03/15/2023 12:58 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:PAINTBRUSH ASSISTED LIVING AND MEMORY CAREFACILITY NUMBER:
107206929
ADMINISTRATOR:JENNIFER VASQUEZFACILITY TYPE:
740
ADDRESS:4356 W ASHLAN AVETELEPHONE:
(559) 275-2000
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:110CENSUS: 75DATE:
03/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennifer VasquezTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management – Incident visit at the facility. LPA met with and explained the purpose of the Case Management with Administrator (AD) Jennifer Vasquez.

The purpose of the visit is to follow up on the following incidents reported to CCLD by the facility. LPA conducted record review and interviews.
1. SOC 341 and Special Incident Report (SIR) were submitted resulting in R2 reporting an altercation with Staff (S1) on 1/4/23.
2. SOC 341 and SIR were submitted resulting in R3 experiencing a fall on 11/12/22.

3.SIR was submitted which reported a medication error which occurred on 1/17/23 involving Resident (R1).

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D.






An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report and Appeal Rights were discussed and left with Jennifer Vasquez, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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 03/15/2023 12:58 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: PAINTBRUSH ASSISTED LIVING AND MEMORY CARE
FACILITY NUMBER: 107206929

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2023
Section Cited

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87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by:

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DEFICIENCY CLEARED - 0n 2/17/23 received additional Medication Management and Medication Error Prevention training.

Additionally,Administrator has agreed to provide an in-service to all staff that assist residents with self administration of medications on error prevention.
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Licensee did not ensure that a facility trained Med Tech assisted a resident with medication safely and effectively as prescribed by the Physician. S1 gave R1 a routine medication as a PRN on 1/14/23 and 1/15/23.

This poses an immediate health, safety or personal rights risk to residents in care

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 AD will provide proof of in-service via sign in sheet to CCLD. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer. To be submitted by 3/27/23 to CCLD.
Type B
03/27/2023
Section Cited

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning….When changes such as… a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person.

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AD has agreed to provide an in-service to Directors and staff responsible for notification and documentation requirements. AD will provide proof of in-service via sign in sheet to CCLD. Sign in sheet will include Inservice topic, date, name and signature of each attendee, and trainer by the due date.

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This requirement was not met as evidenced by:
Licensee did not ensure that R1’s Responsible Party RP) was notified after medication was not given according to Physician orders on 1/15 and 1/16/23. There is no documentation that this notification was provided to RP.
This poses a potential health, safety or personal rights risk to residents in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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