107206929-8-26-2024-24-AS-KBRN-D8HW3Z-20240826165646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206929
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:57:05 PM

Document Has Been Signed on 08/26/2024 04:57 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 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: 67	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jennifer Vasquez		TIME COMPLETED:	05:10 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 Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Jennifer Vasquez. During this visit, LPA toured the facility inside & out. Resident apartments were clean and contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring between 105 – 107 degrees in multiple rooms. LPA observed hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Common dining rooms were observed during meals. Residents enjoyed restaurant style dining service. Knives, cleaning/disinfecting supplies and chemicals were locked are stored separate from food. Medications are centrally stored and locked. A First aid kit contained required items. Facility has multiple visitation and common areas available. LPA walked the outdoor areas to find the grounds to be well kept with walkways, sitting areas and gardens. Doors and passageways are unobstructed throughout the facility including outdoors. An annual Fire system inspection was conducted by Jorgensen Fire Co. on 4/26/24. Fire Extinguishers were serviced and found to be charged. Carbon Monoxide detectors are placed in each apartment. LPA reviewed fire and Emergency Drill logs. LPA conducted resident and staff file reviews. Required postings were observed throughout the facility. Emergency Disaster and Infection Control Plans were reviewed during the inspection. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Personnel Requirements, Storage Space and Incidental Medical and Dental Care Services. See LIC809C for continuation of this report.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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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Document Has Been Signed on 08/26/2024 04:57 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed medications which were accessible in resident rooms: 104, 110, 229, 216 and 238. Additional unknown medications which had been prefilled in medication boxes by dose were observed in 103 and 204. R1 (229) Physician Report states R1 cannot store own medications.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	AD has aggeed to submit a written plan which will include a room check for all Assisted Living rooms. Additionally, the plan will address staff in-service with projected timeline. The in-service sign in sheet with training materials will be submitted to CCL once complete. Written plan to be submitted to CCL by POC date.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 04:57 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: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed accessible cleaning and disinfecting supplies in resident rooms: 103, 204, 229, 244, 238.
	POC Due Date: 09/26/2024
	Plan of Correction
1 2 3 4	AD will submit a written statement to include that all accessible cleaning and disinfecting supplies removed from resident rooms. Additionally, all staff in-service will be provided and a copy of the in-service sign in sheet and training materials will be sent to CCL. Sign in sheet will contain a list of staff along with signatures. Written Statement and in-service sign in will be submitted by poc date.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above inwhich poses/posed a potential health, safety or personal rights risk to persons in care. Staff files reviewed reveal that multiple staff have been trained through Relias on First Aid but have not received appropriate certification as specified.
	POC Due Date: 09/26/2024
	Plan of Correction
1 2 3 4	AD has agreed to audit staff files to identify all staff who need to be re-certified in First Aid by a qualified agency such as the American Red Cross. All identified staff will complete the training. A copy of the certificates of completion will be submitted to CCL by poc 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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

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
	VISIT DATE: 08/26/2024

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An exit interview was conducted and Plan of Correction (POC) developed. A signed copy of this report and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 9/26/24: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan LIC610E, Infection Control Plan (LIC9282 (6/23)) Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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