107208944-5-25-2022-24-AS-MYAG-CES26A-20220525170649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208944
Report Date: 05/25/2022
Date Signed: 05/25/2022 05:06:57 PM

Document Has Been Signed on 05/25/2022 05:06 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:	DIGNITY GARDENS HOME		FACILITY NUMBER:	107208944
ADMINISTRATOR:	KOPACZ, CAMALAH		FACILITY TYPE:	740
ADDRESS:	1637 GETTYSBURG AVE		TELEPHONE:	(559) 449-3711
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 5	DATE:	05/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:21 PM
MET WITH:	Licensee Camalah Kopacz		TIME COMPLETED:	05:15 PM

NARRATIVE

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On 05/25/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Marilyn Gregorio, Caregiver. Licensee Camalah Kopacz was called and arrived shortly and conduct tour with LPA. Four residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings.LPA and Licensee observed at 04:00 p.m. stove top knobs on stove top range. LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed 30 days PPE supplies. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 2 shared residents’ bed to be at least 6 feet apart, one single occupant room and one vacant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. Cleaning supplies were stored and locked in cabinet in the garage. LPA observed fire extinguisher served date: 05/29/21.

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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/31/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 808, Lic 9020, and current liability insurance. LPA received copy of current Administrator certificate. Licensee was provided a copy of this report and appeal rights.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

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 05/25/2022 05:06 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: DIGNITY GARDENS HOME	FACILITY NUMBER: 107208944
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(d)

87705 Care of Persons with Dementia: (d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews conducted, the licensee did not comply with the section cited above when Licensing Program Analyst upon entry observed all four knobs at 3:30 p.m. on stove top range. LPA and Licensee observed during facility tour at 04:00 p.m. two stove knobs on stove top range. During observation two ambulatory dementia residents present sitting in the dining area during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2022
	Plan of Correction
1 2 3 4	Licensee stated that all staff will be retrained on caring for residents with dementia. Document of all staff in-service training will be submitted to department by 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) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

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