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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206953
Report Date: 09/19/2023
Date Signed: 11/09/2023 11:37:06 AM


Document Has Been Signed on 11/09/2023 11:37 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/09/2023 09:54 AM

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

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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Licensee Ron Sandone.

During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed required items in bathrooms which were clean. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguisher was purchased 5/17/23. LPA conducted resident and staff file reviews including medication audit. Infection Control and Emergency Disaster Plans were reviewed.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Hospice Care for Terminally Ill Residents
Appeal for deficiency CCR 87633(b)(6)(B) was granted.

An exit interview was conducted and Plan of Correction (POC) was developed. A copy of this report and Appeal Rights were discussed with and emailed to Ron Sandone.

LPA requested the following updated forms faxed to CCLD by 9/26/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage, Infection Control Plan and Emergency Disaster Plan LIC610E.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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 09/19/2023 02:07 PM - It Cannot Be Edited


Citations on this Visit Report are Under Appeal!

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: BLUEBERRY HILL
FACILITY NUMBER: 107206953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
87633(b)(6)(B)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 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. Hospice note orders daily wound care/dressing changes. There is no documentation of or description of staff training.
POC Due Date: 09/26/2023
Plan of Correction
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Licensee has agreed to obtain step by step instructions as well as have all care staff trained on daily would care needs for Resident (R2). A copy of the instructions as well as signed training log will be provided to CCLD by the POC date. Training log shall include the instructions/orders, name of trainer and date.
Request Denied
Type B
Section Cited
CCR
87633(j)(1)
Hospice Care for Terminally Ill Residents
(1) In caring for a resident's health condition, facility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, 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. Staff were administering blood sugar readings for R1. Physician Report states R1 us unable to perform.
POC Due Date: 09/26/2023
Plan of Correction
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 Licensee immediately notified hospice agency that staff can not perform the testing. A updated plan of care relating to blood sugar readings from the hospice agency will be provided to CCLD by the 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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
LIC809 (FAS) - (06/04)
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