107206929-10-12-2023-24-AS-LPAT-CWK2YX-20231012174928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206929
Report Date: 10/12/2023
Date Signed: 10/12/2023 05:49:35 PM

Document Has Been Signed on 10/12/2023 05:49 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	PAINTBRUSH ASSISTED LIVING AND MEMORY CARE		FACILITY NUMBER:	107206929
ADMINISTRATOR:	JENNIFER VASQUEZ		FACILITY TYPE:	740
ADDRESS:	4356 W ASHLAN AVE		TELEPHONE:	(559) 275-2000
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	110	CENSUS: 85	DATE:	10/12/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Jennifer Vasquez		TIME COMPLETED:	06:00 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	Licensing Program Analysts (LPA) Katie Brown and Lissett Padgett arrived unannounced to conduct the required Annual inspection. LPA met with Administrator Jennifer Vasquez Administrator (AD) and explained the purpose of the visit. Facility was toured with Memory Care Director Traci Horn (MCD). During this visit, LPAs toured the facility inside & out. Resident rooms contained required furnishings and lighting. LPAs observed required items in bathrooms with hot water measuring between 110.1 to114.4 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPAs observed required food supply and paper products. Medications are centrally stored and locked. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors, delayed egress gate was found to be in working order. First aid kits are located throughout the building and found to contain required items. Fire Extinguishers are located throughout the facility and were serviced in 2023. Smoke and Carbon Monoxide detectors are tested annually with Jorgensen fire safety company. LPAs conducted resident and staff file reviews and interviews. Administrator’s re-certification was confirmed to be in pending status and was received by the Department as required. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D. See LIC 809C for continuation of this report.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: PAINTBRUSH ASSISTED LIVING AND MEMORY CARE	FACILITY NUMBER: 107206929
	VISIT DATE: 10/12/2023

NARRATIVE

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An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Resident Care Director, Melinda Ocaranza, whose signature on this form confirms receipt of these documents.

LPA requested the following updated forms faxed to CCLD by 10/19/2023: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan LIC610E, Infection Control Plan review page, Personnel Report (LIC 500), Client Roster (LIC 9020) and Proof of current Liability Coverage

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 05:49 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
FRESNO RO, 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: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/13/2023 Section Cited CCR 87465(h)(1)(C)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h)The following requirements shall apply.....: (1) Medications shall be centrally stored under the following circumstances: (C) ...Because of potential dangers related to the medication itself, ...the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to remove all medications from R4's room. A written statement will be submitted by POC date that states the plan to inservice staff and ensure medications are inaccessible to R4. Additionally an audit of residents rooms will be conducted.
	8 9 10 11 12 13 14	Licensee did not ensure medications were properly stored and/or inaccessible to residents in care. Per R4's physician report, all medications including PRN should be inaccessible. LPA's observed multiple medications in the residence. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 10/23/2023 Section Cited CCR87705(c)(5)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.	1 2 3 4 5 6 7	AD has agreed to submit a copy of updated Physician Report via email to CCLD by POC Date. Additionally, AD has agreed to conduct an audit of resident files to ensure compliance.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Licensee did not ensure R1 and R3 Physician's Report were updated as required. This poses an potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/12/2023 05:49 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
FRESNO RO, 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: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/13/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (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 was not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to perform a deep clean of the ice machine and send picture via email to CCLD by POC date. Additionally, a ice machine cleaning procedure will be implimented to include routine cleaning.
	8 9 10 11 12 13 14	Licensee did not ensure the facility was clean, safe and sanitary. LPA observed mold in the ice machine.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett Padgett	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC809 (FAS) - (06/04)

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