107208897-5-19-2021-24-AS-MTHO-C36QLX-20210519121639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208897
Report Date: 05/19/2021
Date Signed: 05/19/2021 12:16:54 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:	FIG GARDEN VILLA RCF		FACILITY NUMBER:	107208897
ADMINISTRATOR:	MCCARTY, SUSAN		FACILITY TYPE:	740
ADDRESS:	774 W STUART AVE		TELEPHONE:	(559) 261-9530
CITY:	FRESNO	STATE: CA	ZIP CODE:	93704
CAPACITY:	6	CENSUS: 3	DATE:	05/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Susan McCarty, Licensee/Administrator		TIME COMPLETED:	12:45 PM

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On 5/19/21 at 9:05 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an annual inspection. LPA was met by staff and Licensee, and stated purpose of visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one main entrance/exit point.

Facility observed clean 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. Bathroom had trash can with lid and pedal. Hand washing posters were observed by the bathroom sink. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed a 30-day supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Residents files have updated emergency contact information. Administrator certification is current.

The following deficiencies were cited:

1. LPA observed garage exit door from kitchen has dead bolt and lock door lever that opens from inside kitchen area to garage area where window solution, bleach, paint can, garden tools, and power tools were accessible.

2. LPA found S1 did not have a health screening and has been working since 5/6/2020.

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

Exit interview was conducted. A copy of this report and appeal rights were given to Licensee Susan McCarty, whose signature confirms receipt of this report.

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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: FIG GARDEN VILLA RCF	FACILITY NUMBER: 107208897
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed garage exit door from kitchen has deadbolt and lock door lever that opens from inside kitchen area to garage area where window solution, bleach, paint can, garden tools, and power tools were accessible, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2021
	Plan of Correction
1 2 3 4	Licensee installed latch and padlock on kitchen exit door creating inaccessibility to garage area. POC cleared.

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: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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: FIG GARDEN VILLA RCF	FACILITY NUMBER: 107208897
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA found S1 did not have a health screening and has been working since 5/6/2020, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2021
	Plan of Correction
1 2 3 4	Licensee will submit proof of S1's health screening showing good physical health 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 Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: Malia Thao	TELEPHONE: (559) 650-7931
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC809 (FAS) - (06/04)

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