107208897-4-16-2024-24-AS-AWAN-D4DQTR-20240416122734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208897
Report Date: 04/16/2024
Date Signed: 04/16/2024 12:27:44 PM

Document Has Been Signed on 04/16/2024 12:27 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 RCF		FACILITY NUMBER:	107208897
ADMINISTRATOR:	MCCARTY, SUSAN		FACILITY TYPE:	740
ADDRESS:	774 W STUART AVE		TELEPHONE:	(559) 579-5003
CITY:	FRESNO	STATE: CA	ZIP CODE:	93704
CAPACITY:	6	CENSUS: 3	DATE:	04/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Administrator, Susan McCarty		TIME COMPLETED:	12:35 PM

NARRATIVE

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On 04/16/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Susan McCarty.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and shower areas, non-skid mats were observed. Hot water measured at 115.6 degrees F. Kitchen toured, appeared clean, food supply was checked. Exterior tour conducted, all exits open and free of obstructions.

Fire extinguisher serviced on 06/09/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 04/1/2024. All cleaning supplies are locked and secured under the kitchen sink.

LPA reviewed staff and client records. Upon review of P& I records, LPA found resident funds are commingled with facility funds. Medications reviewed and observed to have original labels and be administered as prescribed.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.

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.

LPA is requesting the following documents be submitted to the Fresno CCL office by 04/30/2024: 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

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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 04/16/2024 12:27 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
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: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87217(e)

87217 Safeguards for Resident Cash, Personal Property, and Valuables: (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money. 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 when residents funds were commingled with facility funds, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a statement detailing the steps the facility will take to ensure the requirements for section 87217 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	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC809 (FAS) - (06/04)

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