107208848-2-2-2024-24-AS-KBRN-D23VAZ-20240202151646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208848
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:17:04 PM

Document Has Been Signed on 02/02/2024 03:17 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:	EVERSPRING RETIREMENT HOME		FACILITY NUMBER:	107208848
ADMINISTRATOR:	AZADEH AKBARNEJAD		FACILITY TYPE:	740
ADDRESS:	5738 N. LOLA AVE		TELEPHONE:	(559) 907-2596
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	6	CENSUS: 6	DATE:	02/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Alex Babakhani		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Asst. Administrator/Facility Designee (AD) Alex Babakhani. During this visit, LPA toured the facility inside & out. Resident bedrooms are found in good repair, contained required furnishings and lighting. The resident bathroom was clean and in good repair. LPA observed required hygiene items and grab bars. Towels, extra bedding, and linens were stored and available for use. Resident bathroom hot water measured 107.4 degrees. The kitchen was clean, in good repair with necessary items and appliances. LPA observed required water, food supply, PPE and paper products. Knives/sharps, are locked and stored separate from food. Medications are centrally stored in a locked cabinet in the kitchen. A First aid kit contained required items. There are visitation areas available inside and out. LPA observed a self-releasing gate and windows have screens in good repair. Smoke and Carbon Monoxide detectors are present and were tested during the visit. The Fire extinguishers were purchased 4/12/2023. LPA conducted resident and staff file reviews. The Emergency Disaster Plan and Infection Control Plans were reviewed, AD has agreed to update both. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Storage Space and Personal Accommodations and Services. An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided. See Lic809C for continuation of this report

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

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 02/02/2024 03:17 PM - It Cannot Be Edited

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: EVERSPRING RETIREMENT HOME	FACILITY NUMBER: 107208848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)(1)

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. (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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, 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. Laundry room door to garage is not secured/locked. Cleaning supplies and tools are stored in the garage. A disposable razor was stored in the bathroom with hygiene supplies. Razor was immediately removed.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	AD has agreed to install a keyless locking door knob on the door leading to the garage. A lock will be placed on the bathroom cabinet where razors are kept. AD will provide a picture of both secured areas to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	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. R1's bedroom furniture does not ensure clear passageway and causes obstruction in a non-ambulatory room with an emergency exit.
	POC Due Date: 02/16/2024
	Plan of Correction
1 2 3 4	AD has agreed to rearrange the furniture in R1's bedroom to ensure clear passageway free of obstruction. A picture 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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6

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: EVERSPRING RETIREMENT HOME	FACILITY NUMBER: 107208848
	VISIT DATE: 02/02/2024

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LPA requested the following updated forms faxed to CCLD by 2/16/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan (LIC610D), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402) Personnel Report (LIC 500). Client Roster (LIC 9020), Proof of current Liability Coverage and the updated Infection Control Plan.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024

LIC809 (FAS) - (06/04)

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