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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208255
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:35:10 AM

Document Has Been Signed on 12/13/2022 11:35 AM - 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:MCWEALTH CARE HOME 2FACILITY NUMBER:
107208255
ADMINISTRATOR:MCWEALTH, JOSHUAFACILITY TYPE:
735
ADDRESS:4683 W PROVIDENCE AVENUETELEPHONE:
(559) 458-3947
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 4CENSUS: 4DATE:
12/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:April GaylordTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted an unannounced Case Management – Deficiencies visit. LPA met with and explained the purpose of the visit with April Gaylord.

The purpose of the Case Management is to follow up on the Restricted Health Condition Care Plan (CP) for R1. During the Annual visit on 12/5/22, LPA requested to review the CP and Physician's Report of R1. Neither of the documents were located in the file. AD did not submit a complete CP to LPA for review.

Deficiencies for Restricted Health Condition Care Plan is being cited on the attached LIC9099-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 April Gaylord, whose signature on this form confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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 12/13/2022 11:35 AM - It Cannot Be Edited


Created By: Katie Brown On 12/13/2022 at 11:05 AM
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: MCWEALTH CARE HOME 2
FACILITY NUMBER: 107208255

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
80092.2(a)

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80092.2 Restricted Health Condition Care Plan (a) If the licensee of an ARF chooses to care for a client with a restricted health condition, as specified in Section 80092, the licensee shall develop and maintain, as part of the Needs and Services Plan, a written Restricted Health Condition Care Plan. This requirement was not met as evidenced by:
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Administrator has agreed to develop and maintain a Restricted Health Care Plan for R1 which meets all requirements. A complete Restricted Health Condition Care Plan and Physician’s Report will be submitted by the due date.
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Based on interview and record review, the facility did not develop and maintain a written Restricted Health Condition Care Plan for R1. R1 does not have a complete Physician’s Report. This poses an immediate health and safety risk to persons in care
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Type A
12/14/2022
Section Cited
CCR80092.1(a)(e)

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80092.1 General Requirements for Restricted Health Conditions (a) A client with a restricted health condition specified in Section 80092 may be admitted or retained in an adult CCF if all requirements in Sections 80092.1(b) through (o) are met. (e) The client must be under the medical care of a licensed professional. This requirement was not met as evidenced by:
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Administrator has agreed to request Licensed Professional Services through CVRC. An appointment will be made for R1 to be seen by Physician and required documents to be completed. Confirmation of this request and appointment will be sent to LPA by the due date.
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Based on interview and record review, R1 is not under the care of a Licensed Professional related to the care and oversight of the restricted health condition as required by CCL and CVRC. This poses an immediate 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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
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