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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208886
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:26:07 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:NORTHWEST VILLAFACILITY NUMBER:
107208886
ADMINISTRATOR:HANSEN, ANDREAFACILITY TYPE:
740
ADDRESS:542 W. BROWNING AVETELEPHONE:
(559) 448-8964
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY:6CENSUS: 5DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Andrea Hansen, Licensee/AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 12/21/21 at 8:45 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason fro inspection and was granted entry by staff. Licensee/Administrator Andrea Hansen arrived a short time later.

LPA toured facility with staff. Facility set at comfortable temperature. All bedrooms observed with sufficient furniture and lighting. Hot water measured 113 degrees F in west hall bathroom. Sufficient linen and toiletries observed. Smoke and carbon monoxide detectors tested and operational. Fire extinguisher was last serviced 3/4/21. Sharps observed locked in top cabinet above stove. Chemicals observed locked in laundry room top cabinet. 2-day perishables and 7-day non-perishables supply of food observed. Centrally stored medication observed locked in laundry room top cabinet and have at least 30-day supply. Sample of staff health screening observed. Resident emergency contact information current.

The following deficiencies observed:
1. Both fire exit gates observed with broken pulling chains and latches not self-latching. West side fire exit gate observed sticking to walkway making it hard to push open. Bottom of window screen in front dining room is tattered.
2. Two paint cans observed in accessible east hall closet and open storage area in backyard. One shovel observed accessible in open storage area in backyard.

The following updated forms are to be submitted to CCL within 2 weeks:
LIC308, LIC500, LIC610E, proof of current liability insurance, copy of current Administrator certificate

Deficiency is being cited based on LPA's observations and interviews in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided via email and an electronic read receipt confirms receiving this document. Licensee was informed to select yes when prompted to send a read receipt. Facility Representative signature on file.

SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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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: NORTHWEST VILLA
FACILITY NUMBER: 107208886
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 and interviews, the licensee did not comply with the section cited above. LPA observed both fire exit gates with broken pulling chains and latch not self-latching. West side fire exit gate observed sticking to walkway making it hard to push open. Bottom of window screen in front dining room is tattered, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee will submit proof of both fire exit gates' pulling chains operating and both latches are replaced to be self-latching to CCL by POC due date. Proof of west side fire exit gate opening and closing with ease and proof of front dining room window screen replaced to be sent to CCL by POC due date of 12/28/21.
Type A
Section Cited
CCR
87309(a)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPA observed two paint cans accessible in the east hall closet and open storage area in backyard and one shovel observed accessible in open storage area in backyard, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee immediately removed all paint cans and shovel into east hall closet. Licensee will submit proof of installed locking door knob on east hall closet door 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 XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021
LIC809 (FAS) - (06/04)
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