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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208852
Report Date: 09/19/2024
Date Signed: 09/24/2024 04:36:37 PM


Document Has Been Signed on 09/24/2024 04:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:A PLACE CALLED HOME RESIDENTIAL CARE 6FACILITY NUMBER:
107208852
ADMINISTRATOR:MURCHISON, DAVIDFACILITY TYPE:
740
ADDRESS:3041 SERENA AVETELEPHONE:
(559) 213-7251
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY:6CENSUS: 6DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:David MurchisonTIME COMPLETED:
02:30 PM
NARRATIVE
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On 09/19/2024, Licensing Program Analyst (LPA) M. Vega & B. Miranda arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. Administrator was contacted and arrived a short time later. LPA toured facility with Administrator David Murchison.

The facility was observed to be at a comfortable temperature, of 72 degrees F. Facility is free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. Department phone number and infection prevention information signs were posted thought the facility.

Inspecting kitchen LPA observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. An emergency disaster supply was observed.

Fire extinguisher was observed with a service date of 04/2024. All 6 residents’ bedrooms were observed to be with comfortable temperature. Bathroom water temperature was tested and recorded reading of 115 degrees F.
Medications observed to be locked in a cabinet in the kitchen. LPA reviewed a sample of Centrally Stored Medication Logs. LPA observed R1 was being given CBD oil which was not logged on the Centrally Stored Medication Log, deficiency issued. Cleaning supplies were observed to be in a locked cabinet in the laundry room. An outdoor seating area was observed for residents in care.

LPA reviewed a sample of Staff and Resident files. Resident files observed to have updated information, 2 of the staff files were needing documentation which Administrator was informed.

Deficiencies were cited under Title 22. LIC 809 C - Continuation
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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 8


Document Has Been Signed on 09/24/2024 04:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL CARE 6
FACILITY NUMBER: 107208852

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Plan of correction need prescription and to have Centrally stored Medication log updated.
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: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: A PLACE CALLED HOME RESIDENTIAL CARE 6
FACILITY NUMBER: 107208852
VISIT DATE: 09/19/2024
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Administrator requested for staff to sign report. Exit interview conducted. Report was signed and copy of this report and appeal rights were provided for facility records.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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