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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208889
Report Date: 11/15/2023
Date Signed: 11/16/2023 12:20:43 PM


Document Has Been Signed on 11/16/2023 12:20 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 ASC, 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:
11/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Adminsitrator, Lisa Pua TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced Case Management visit. LPA met with facility Administrator, Lisa Pua and explained the purpose of the visit.

LPA Hurt collected records for Resident 1 including Physician's report, Needs and services plan, and care notes. LPA Hurt reviewed Resident 1's Physician Report which is more than 3 years old. Resident 1 should have a Physicians report updated annually.

The following Deficiencies are being cited Per Title 22 Regulations.

Exit interview conducted with Administrator, Lisa Pua, and a copy of this report along with appeals right provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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 11/16/2023 12:20 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 ASC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: LAVERNE SENIOR CAREHOME
FACILITY NUMBER: 107208889

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Administrator will send current Medical Assesment for Resident 1 to LPA by 11/29/2023 POC date.
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The following requirement has not been met as evidenced by: Resident 1's Physician Report was last updated on 02/02/2020 which poses a potential, health, safety or personal rights risk to residents in care.
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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) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
LIC809 (FAS) - (06/04)
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