107208889-10-13-2021-24-AS-MYAG-C7RTNL-20211013145255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208889
Report Date: 10/13/2021
Date Signed: 10/13/2021 02:53:53 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:	LAVERNE SENIOR CAREHOME		FACILITY NUMBER:	107208889
ADMINISTRATOR:	BAUTISTA, ARLENE		FACILITY TYPE:	740
ADDRESS:	3194 LAVERNE AVE		TELEPHONE:	(559) 292-0074
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Caregivers Bienvel Yap and MaryLena Javate		TIME COMPLETED:	01:15 PM

NARRATIVE

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On 10/13/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by Caregivers Bienvel Yap and MaryLena Javate. Arlene Bautista, Administrator was called by caregiver. Administrator states unable to meet with LPA and authorized caregiver Bienvel to received report and tour facility with LPA. All six residents were present during the inspection.

LPA conducted tour with caregivers. Facility staffs was observed with mask on. 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. LPA checked residents’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguishers with a service date of: 06/16/20. Cleaning supplies were stored and locked in garage cabinet and under kitchen sink.

All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. Hand washing posting by all sinks. Social distancing and cough etiquette postings observed in facility. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 shared resident’s bedrooms to be at least 6 feet apart and 2 bedrooms that are single occupant.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to 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 conducted. The following updated forms were requested: LIC 308, LIC 500, LIC 610E, LIC 9020, current liability insurance, and updated Administrator Certificate. Please submit the above forms to Fresno CCL by: 10/19/21.

Administrator and caregiver were informed that as COVID-19 precautionary measure, this report and appeal Rights were provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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: LAVERNE SENIOR CAREHOME	FACILITY NUMBER: 107208889
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire Extinguisher has a service date of 06/16/2020, which poses an immediate health and safety risk to the residents.
	POC Due Date: 10/14/2021
	Plan of Correction
1 2 3 4	Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 10/14/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC809 (FAS) - (06/04)

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