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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206953
Report Date: 01/26/2023
Date Signed: 01/26/2023 03:02:54 PM

Document Has Been Signed on 01/26/2023 03:02 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:BLUEBERRY HILLFACILITY NUMBER:
107206953
ADMINISTRATOR:CASTIGADOR, YOLANDAFACILITY TYPE:
740
ADDRESS:7447 N RIVERSIDE DRIVETELEPHONE:
(559) 981-5630
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 6CENSUS: 5DATE:
01/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Yolonda CastigadorTIME COMPLETED:
03:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced and conducted a case management visit. LPA met with and explained the purpose of the visit with Administrator (AD) Yolanda Castigador.

During the visit, LPA toured the facility, conducted interviews and reviewed resident records.

LPA observed the following:
1. Chemicals & cleaning supplies were stored in an unlocked cabinet under the kitchen sink
2. Resident (R1) has personal PRN medications at bedside and in common area
3. R1, R2, R3 do not have Physician orders for ½ bed rails


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 was developed. A copy of this report and Appeal Rights were discussed and left with Yolanda Castigador , whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 03:02 PM - It Cannot Be Edited


Created By: Katie Brown On 01/26/2023 at 02:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLUEBERRY HILL
FACILITY NUMBER: 107206953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
87462(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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AD immediately removed the medications from R1's bedside table as well as tray in common area. The deficiency is cleared.
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Licensee did not ensure all medications were centrally stored and locked. LPA observed tums at R1's bedside as well as Aleve and Vitamins on R1's personal table in the common area.
This poses an immediate health, safety or personal rights risk to persons in care.
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Type B
02/03/2023
Section Cited
CCR87608

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal…..Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record…. This requirement was not met as evidenced by:
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AD agrees to obtain a physicians order for R1, R2 and R3 for the use of the 1/2 rails. AD will submit a copy of the orders as well as a copy of proof of training on the use of postural supports. AD agrees to submit by the due date.
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Licensee did not ensure that a physician's order was obtained for the use of 1/2 bedrails for R1, R2 and R3. LPA observed 1/2 rails on the resident's hospital beds.

This poses a potential health, safety or personal rights risk to persons 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 Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/26/2023 03:02 PM - It Cannot Be Edited


Created By: Katie Brown On 01/26/2023 at 02:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLUEBERRY HILL
FACILITY NUMBER: 107206953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
87039(a)

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87309 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement was not met as evidenced by:
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Facility staff immediately removed and placed the items in a locked cabinet. AD has agreed to replace the lock on this cabinet. AD will submit pictures of the new locks on the cabinet to LPA by the due date.
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Licensee did not ensure that all chemicals and disinfecting products were locked and inaccessible to residents. LPA observed cleaning and disinfecting products srored under the kitchen sink which was unlocked.

This poses a potential health, safety or personal rights risk to persons 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 Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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