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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208262
Report Date: 12/01/2021
Date Signed: 12/01/2021 08:42:15 PM

Document Has Been Signed on 12/01/2021 08:42 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:LAKEWOOD HAVENFACILITY NUMBER:
107208262
ADMINISTRATOR:POLLAN, ELSA SFACILITY TYPE:
740
ADDRESS:362 W STUART AVENUETELEPHONE:
(559) 374-6692
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 5DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elsa Pollan, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 12/1/21 at 9:45 AM, Licensing Program Analysts (LPAs) Malia Thao and Lisa Salazar arrived unannounced to conduct an Annual inspection. LPAs explained reason for inspection and was granted entry by staff. Administrator (ADM) Elsa Pollan arrived about 30 minutes later.

LPAs toured inside and outside of the facility with staff. Food supply of 2-day perishables and 7-day non-perishables observed. Smoke and carbon monoxide detectors observed operational. Facility set at comfortable temperature. All bedrooms have sufficient furniture and lighting. Centrally stored medication observed in locked hall closet.

The following deficiencies observed:
1. Hot water in hallway bathroom measured at 121.8 degrees F.
2. R1 does not have a written hospice care plan in place. Hospice initiation for R1 began on 11/15/21.
3. LPA observed one retractable utility knife, one screwdriver, two shaving razors, and two comet cleaner cans accessible in hallway bathroom cabinet and drawers.
4. LPA observed all four bedroom and two bathroom windows to be covered in dust and mold/mildew, bedroom #2 crown molding observed covered in insect droppings, all air vents covered in dust, bedroom #4 window screen frame observed bent and in disrepair, wall next to top and bottom ends of kitchen cabinet/counter by dining room window observed black and wall material coming away from wall.
5. LPA found that all five resident's admission agreements were incomplete and missing initials throughout document. R2 missing signature of admission agreement. R5 is missing an admission agreement.
6. ADM's Administrator certificate is expired as of 11/1/21. ADM admitted having incomplete training required and has not submitted an application for Administrator Recertification.
7. RCFE Complaint Poster (PUB475) is not posted in the facility and Administrator could not produce a copy of PUB475 to post during inspection.
8. Administrator could not produce R5's resident records for review upon request. Continue on LIC809-C.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 21
Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 02:38 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

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. Administrator does not have written hospice care plan for R1 in place. Hospice initiation for R1 began on 11/15/21, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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Administrator will submit proof of R1's written hospice care plan to CCL by POC due 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
Page: 13 of 21
Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 02:38 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed one retractable utility knife, one screwdriver, two shaving razors, and two comet cleaner cans accessible in hallway bathroom cabinet and drawers, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Administrator immediately removed all items and stored items in locked garage. POC cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


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Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 02:38 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPA observed all four bedroom and two bathroom windows to be covered in dust and mold/mildew, bedroom #2 crown molding observed covered in insect droppings, all air vents covered in dust, bedroom #4 window screen frame observed bent and in disrepair, wall next to top and bottom ends of kitchen cabinet/counter by dining room window observed black and wall material coming away from wall, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2021
Plan of Correction
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Administrator will clean all four bedroom and two bathroom windows, bedroom #2 crown molding, and all air vents; replace window screen for bedroom #4, and repair wall by kitchen cabinet/counter end by dining room window by POC due date. POC inspection will be conducted.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

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. LPA found that all five resident's admission agreements are incomplete and missing initials throughout document. R2 missing signature of admission agreement. R5 is missing an admission agreement, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2021
Plan of Correction
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Administrator will complete all pages of admission agreement in full for all five residents by POC due date. POC inspection to be conducted.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


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Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 02:46 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water in hallway bathroom measured at 121.8 degrees F, which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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Administrator will submit proof of hot water in hallway bathroom to be measured within regulation to CCL by POC due date.
Type A
Section Cited
CCR
87407
87407 Administrator Recertification Requirements
To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview, the licensee did not comply with the section cited above. Administrator certificate is expired as of 11/1/21. ADM admitted having incomplete training required for re-certification and has not submitted an application to the Department's Administrator Certification Section for Administrator Recertification, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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Administrator will submit proof of the certified mail labeled envelope to the Department's Administrator Certification Section, copy of completed application for re-certification, and copy of check payment for Administrator Recertification to CCL by POC due 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262
VISIT DATE: 12/01/2021
NARRATIVE
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Continued from LIC809.

The following updated documents to be submitted to CCL within two weeks:

LIC308, LIC610E(new revision), current liability insurance

Deficiencies are being cited based on LPAs' observations, interviews, and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted and Plans of Corrections were reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and emailed to Administrator Elsa Pollan with "Read Receipt" to confirm receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 03:53 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The facility did not have the RCFE Complaint Poster (PUB475) posted in the facility and Administrator could not produce a copy of PUB475 to post during inspection, which poses a potential personal rights risk to persons in care.
POC Due Date: 12/08/2021
Plan of Correction
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Administrator will post PUB475 in facility entryway by POC due date. POC inspection to be conducted.

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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
Page: 3 of 21
Document Has Been Signed on 12/01/2021 08:42 PM - It Cannot Be Edited


Created By: Malia Thao On 12/01/2021 at 03:58 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: LAKEWOOD HAVEN
FACILITY NUMBER: 107208262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506
87506 Resident Records
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above. Administrator could not produce R5's resident records upon request, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2021
Plan of Correction
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Administrator will have R5's resident records available for LPA review by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021


LIC809 (FAS) - (06/04)
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