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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208889
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:33:41 AM


Document Has Been Signed on 12/01/2022 11:33 AM - 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:LAVERNE SENIOR CAREHOMEFACILITY NUMBER:
107208889
ADMINISTRATOR:BAUTISTA, ARLENEFACILITY TYPE:
740
ADDRESS:3194 LAVERNE AVETELEPHONE:
(559) 292-0074
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:: Bienvel “Ben” Yap, caregiver and Elisa "Lisa" Pua, AdministratorTIME COMPLETED:
11:45 AM
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On 12/1/22, Licensing Program Analyst (LPA) Mai 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 caregiver Bienviel “Ben” Yap. Elisa “Lisa” Pua, Administrator was called and arrived later during inspection. LPA conduct facility tour with caregiver. All five residents were present during the inspection.

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. COVID-19 related signs and cough etiquette postings observed in facility. LPA observed fire extinguisher served date: 10/17/22.

LPA observed residents’ 30-day medication supplies in locked cabinet in kitchen. LPA observed resident’s medication bottle on kitchen counter unlock. Food supply was checked and appeared to be an adequate supply. At 08:56 AM, LPA and caregiver observed in the refrigerator in the kitchen milk with expired date: 11/24/22. LPA observed a 30-day PPE supplies.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared residents’ bed to be at least 6 feet apart and 3 single occupant room. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPA observed hand washing posting by all sinks.

Cleaning supplies were stored and locked in garage. At 09:57AM, LPA and caregiver observed in the refrigerator in the garage hamburger buns with expired date: 09/14/22. The exterior tour was conducted. LPA and staff observed a paint bucket and chemical bottle outside unlocked. Side gate was self-closing and self-latching.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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
VISIT DATE: 12/01/2022
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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 documents are requested and submitted to Fresno CCL by: 12/7/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, current liability insurance, and current Administrator Certificate. A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2022 11:33 AM - 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: LAVERNE SENIOR CAREHOME
FACILITY NUMBER: 107208889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309(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 LPA and caregiver observed a paint bucket and a bottle of Muriatic Acid outside on the side of the facility accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Caregiver immediately removed paint bucket and Muriatic Acid bottle into locked garage. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(2)
87465 (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 LPA and caregiver observed a three medications bottle on kitchen counter unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Caregiver immediately removed and stored medications in locked medication shelf. POC cleared during visit.

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) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/01/2022 11:33 AM - 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: LAVERNE SENIOR CAREHOME
FACILITY NUMBER: 107208889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
87555(a) General Food Service Requirements-The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ...All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 LPA and caregiver observed a expired milk date of 11/24/22 and two hamburger bun package expired date of 09/14/22 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2022
Plan of Correction
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Licensee agrees to audit food once a week. Licensee will submit to the department with documentation of plan to ensure regulations are met which includes date of the week food will be audit. Documentation shall be submitted by the 12/7/22.
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) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4