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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208837
Report Date: 09/14/2021
Date Signed: 09/14/2021 04:11:22 PM

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:CATUIRA HOME IIFACILITY NUMBER:
107208837
ADMINISTRATOR:KOPACZ, CAMALAHFACILITY TYPE:
740
ADDRESS:2478 HANSON AVENUETELEPHONE:
(559) 515-6071
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Camalah Kopacz Administrator, Oscar Aninon and Margarita Viloria caregiver TIME COMPLETED:
11:30 AM
NARRATIVE
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On 09/14/2021, Licensing Program Analysts (LPA) M. Yang and A. Walton arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with caregiver Oscar Aninon and Margarita Viloria. Caregivers call Administrator Camalah Kopacz. LPAs conduct tour with caregivers. Camalah arrived later during tour. All five residents were present during the tour.

Facility tour conducted with Caregiver. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. LPAs observed bathrooms did not have trash cans with lid. Hand washing posters were observed by the bathroom sink. LPAs observed residents bed to be at least 6 feet apart.

LPAs checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. LPAs did not observe 30-day PPE supplies. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. A sample of residents do not have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit interview was conducted. A plan of correction was developed and reviewed with the administrator. Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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 5
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: CATUIRA HOME II
FACILITY NUMBER: 107208837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
(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.

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 when LPAs observed 1 bottle of bleach under under the kitchen sink accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/14/2021
Plan of Correction
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Licensee immediately removed the bottle of bleach from under the sink and placed the bottle in a locked cabinet in the laundry room. POC cleared during visit.
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: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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