<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208897
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:20:11 PM

Document Has Been Signed on 04/13/2023 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:FIG GARDEN VILLA RCFFACILITY NUMBER:
107208897
ADMINISTRATOR:MCCARTY, SUSANFACILITY TYPE:
740
ADDRESS:774 W STUART AVETELEPHONE:
(559) 261-9530
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Administrator, Susan McCartyTIME COMPLETED:
12:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/13/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Facility staff contacted Administrator, Susan McCarty who arrived a short time later. LPA met with Administrator.

Facility tour conducted with Administrator. Facility was at a comfortable temperature, odor free, and pathways were clear from obstructions. Common areas were furnished with adequate seating a lighting available. LPA toured resident rooms. Bedrooms are single occupant. Bedrooms observed to have the required furnishings and had adequate lighting. Resident bathrooms toured. Bathrooms were equipped with securely fastened grab bars and non-skid mats. Hot water measured at 116.8 degrees F. Facility kitchen toured. Knives/Shaps observed locked and inaccessible in a box in the cabinet. Cleaning supplies observed to be inaccessible under the kitchen sink. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Facility exterior toured. Facility pool observed to have a locked gate around the perimeter. No fire clearance issues observed during this visit.

Smoke detector and carbon monoxide observed to be operational during this inspection. Last fire drill was conducted in February 2023. Fire extinguisher was observed to be purchased on 06/11/2022. Resident and staff records reviewed. LPA reviewed resident medications. Upon review of medications, LPA observed a medication for R1 was not listed on the MAR. First-Aid kit observed to have required items.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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
VISIT DATE: 04/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA is requesting the following documents be submitted to the Fresno CCL office by 04/27/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Susan McCarty, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/13/2023 12:20 PM - It Cannot Be Edited


Created By: Alexandria Walton On 04/13/2023 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: FIG GARDEN VILLA RCF
FACILITY NUMBER: 107208897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when 1 out of 4 residents did not have a prescribed medicaion listed on the centrally stored log/ MAR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the steps the faciltiy will take to ensure the requirement for section 87465 are met to the Fresno CCL office by the POC due date.
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
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3