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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208936
Report Date: 08/06/2024
Date Signed: 08/06/2024 04:26:43 PM


Document Has Been Signed on 08/06/2024 04:26 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 RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:DEANNA'S PLACEFACILITY NUMBER:
107208936
ADMINISTRATOR:BENOV, DEANNA LFACILITY TYPE:
740
ADDRESS:951 E ALLUVIAL AVETELEPHONE:
(559) 570-8763
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY:6CENSUS: 5DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Camalah KopaczTIME COMPLETED:
04:25 PM
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On 08/06/2024 Licensing Program Analysts (LPAs) M. Vega & B. Miranda arrived at the facility unannounced to conduct a required Annual Inspection. LPAs introduced themselves and stated the purpose of visit. LPAs were allowed into the facility and new Licensee Camalah Kopacz was contact and arrived later. Facility is currently in the middle of changing owners.

Facility current capacity is 6 with a current census of 5. Facility has 6 bedrooms and 2 bathrooms, 5 of the bedrooms are for residents and the 6th bedroom is for staff.

LPA toured the facility inside and out including entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPAs observed the facility to be clean, clutter, and odor free.

All fire exit routes were free and clear of obstructions. Smoke detectors and carbon monoxide detectors were tested and are in working condition. Fire extinguishers have been services as of 5/22/2024 and are in good standing. Smoke alarms are in working condition. LPAs observed knives and cleaning supplies to be locked and inaccessible to residents. Water temperature in the common bathroom was checked and read at 131.8 degrees Fahrenheit.

Medications are stored in a locked cabinet in the laundry area. LPAs observed medications and centrally stored medication log, two of R1’s medication count was off.

Citations were issued per the California Code of Regulations Title 22.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights was/were provided to Camalah Kopacz.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 2


Document Has Been Signed on 08/06/2024 04:26 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 RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: DEANNA'S PLACE
FACILITY NUMBER: 107208936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 which poses an immediate health, safety or personal rights risk to persons in care. Water temperature in the common bathroom was checked and read at 131.8 degrees Fahrenheit.
POC Due Date: 08/07/2024
Plan of Correction
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licensee will adjust water heater and provide verification to LPA.
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed medications and centrally stored medication log, two of R1’s medication count was off.
POC Due Date: 08/07/2024
Plan of Correction
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Licensee will be conduction medication training. Training will be completed by 8/20/24 and verification will be sent to LPA.
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) 272-4781
LICENSING EVALUATOR NAME: Martin VegaTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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