Community Care Licensing

Document Has Been Signed on 05/08/2023 12:34 PM - It Cannot Be Edited

FACILITY NAME:	STATE HOUSE		FACILITY NUMBER:	107206945
ADMINISTRATOR:	FLETCHER, CLINARD		FACILITY TYPE:	735
ADDRESS:	5733 N STATE ST		TELEPHONE:	(559) 681-1470
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY: 4		CENSUS: 4	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Denise Blunt		TIME COMPLETED:	11:26 AM

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SUPERVISORS NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023

Link to Parent Document Below:

FACILITY NAME: STATE HOUSE	FACILITY NUMBER: 107206945
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

Type B

Section Cited

CCR

80075(b)(6)(D)(1)

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information: (1) The specific symptoms which indicate the need for the use of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of the facility MAR, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the facility does not maintain a PRN log to document the required information when a PRN medication is given.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to obtain or create a PRN log that will allow staff to document all required elements. An in-service will be provided to all staff that assist with medication pass. The sign in sheet will record the name and signature of each staff, date, length of time, trainer and description of the training provided. A copy of the log and in-service sign in sheet will be emailed to CCLD buy the POC date.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Katie Brown LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023