107208977-6-16-2023-24-AS-AWAN-CSURXB-20230616132428

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208977
Report Date: 06/16/2023
Date Signed: 06/16/2023 01:24:54 PM

Document Has Been Signed on 06/16/2023 01:24 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:	JAN-ROY PLACE OF FRESNO		FACILITY NUMBER:	107208977
ADMINISTRATOR:	HOPPER, JOYCELYN		FACILITY TYPE:	740
ADDRESS:	4766 EAST ILLINOIS AVE		TELEPHONE:	(559) 940-9708
CITY:	FRESNO	STATE: CA	ZIP CODE:	93702
CAPACITY:	6	CENSUS: 6	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Administrator, Joycelyn Hopper		TIME COMPLETED:	01:43 PM

NARRATIVE

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On 06/16/2023, Licensing Program Analyst (LPA) Walton arrived at the facility unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed to enter the facility. Facility Staff contacted Administrator, Joycelyn Hopper via telephone. Administrator arrived a short time later.

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. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 107.1 degrees F. Kitchen toured, appeared clean, LPA observed an adequate supply of food. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 09/23/2021. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted November 2021. All cleaning supplies are locked in secured under kitchen sink.

LPA reviewed staff and client records. LPA did not observe documentation for training in the personnel records for 3 out of 3 clients. Upon review of resident records, Administrator was unable to provide bank statements to account for client P&I funds. Medications reviewed and observed to have original labels and be administered as prescribed.

Deficiencies are 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 was discussed and provided to Administrator, Joycelyn Hopper, whose signature on this form confirms receipt of this document.

CONTINUED TO 809-C

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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: JAN-ROY PLACE OF FRESNO	FACILITY NUMBER: 107208977
	VISIT DATE: 06/16/2023

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LPA is requesting the following documents be submitted to the Fresno CCL office by 06/30/2023:

· LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria Walton	TELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2023 01:24 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: JAN-ROY PLACE OF FRESNO	FACILITY NUMBER: 107208977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 it was observed that 3 out of 3 staff do not have updated training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements of the above section are met. Licensee will submit proof of training to the Fresno CCL by 09/01/2023.

Type B

Section Cited

CCR

87217(c)

87217 Safeguards for Resident Cash, Personal Property, and Valuables: (c) Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. 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 6 out of 6 residents in care did not have updated Cash Resource Information which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee agrees to submit a written 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.

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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 06/16/2023 01:24 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: JAN-ROY PLACE OF FRESNO	FACILITY NUMBER: 107208977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. 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 the fire extinguisher in the facility was observed to be last serviced on 09/23/2021, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/17/2023
	Plan of Correction
1 2 3 4	Licensee agrees to replace or service the existing fire extinguisher and submit proof of correction 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: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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