107208995-8-15-2024-24-AS-JLEL-D86T45-20240815142320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 08/13/2024
Date Signed: 08/15/2024 02:24:20 PM

Document Has Been Signed on 08/15/2024 02:24 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	CARMEL VILLAGE AT CLOVIS		FACILITY NUMBER:	107208995
ADMINISTRATOR:	POPE, LINDA		FACILITY TYPE:	740
ADDRESS:	1650 SHAW AVENUE		TELEPHONE:	(559) 297-4900
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	127	CENSUS: 90	DATE:	08/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator: Linda Pope		TIME COMPLETED:	06:00 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 8/13/2024, Licensing Program Analysts (LPAs) J. Leffall and K.Kaur arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by receptionist, stated the purpose of the visit and met with Administrator (A1) Linda Pope. LPA conducted tour of facility with A1. Residents were observed seating in lobby, dining area and activity room. The facility was observed to be at a comfortable temperature, clean, in good repair with no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 11/21/2023. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer and walk-in refrigerator. Refrigerator temperature was observed maintained at 34-degree F. and freezer was observed maintained at -10-degree F. At 9:43 AM LPAs observed Trash room unlocked with Carpet Shampoo. LPAs toured on the 1^st floor: a sample of resident bedrooms, activity room, club room, dining room and fitness center. Tour continued to 2^nd floor. At 10:12AM LPAs observed Clorox bleach and Shout cleaner unlocked in residents’ laundry. Second floor observed LPA’s 7 Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. LPAs observed securely fastened grab bars next to toilet and all tub/shower areas. 7 out of 7 residents rooms observed without non-skid mats. 6 out of 7 residents bathroom temperatures measured above 120 F. LPAs completed a medication audit. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. LPAs observed R1’s medication was not logged in Centrally Stored Medication and Destruction Record (CSMDR). LPAs observed CSMDR was incomplete/ missing information. Based on record review LPAs observed 3 out of 3 residents that had missed medication. A sample of staff files were reviewed to have the required documents. A sample of resident’s files were reviewed to have all the required documents.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 08/15/2024 02:24 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CARMEL VILLAGE AT CLOVIS	FACILITY NUMBER: 107208995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

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
1 2 3 4	Based on observation the following resident's rooms had a water temperature of: Room 110 is 124 degrees Room 226 is 125 degrees Room 239 is 125.2 degrees Room 232 is 128.5 degrees Room 342 is 127.6 degrees Room 308 is 122.4 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator to submit statement of intent to adjust water heater temperatures to bring resident's water temperature between 105-120 degrees.

Type A

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation 7 out of 7 residents were observed with no shower mats or strips which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator to submit written statement of intent to check all resident's bathrooms and install shower mats or shower strips.

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2024 02:24 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CARMEL VILLAGE AT CLOVIS	FACILITY NUMBER: 107208995
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation Clorox bleach and Shout observed in 2nd floor laundry room unlocked. Carpet shampoo observed in trash room unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator to submit a written statement that all chemicals are stored in a locked facility.

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation Centrally stored medication log was observed without start date. (R1) medication Ferrous Sulfate was not found in CSMDR which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Administrator to submit statement of intent to conduct inservice training and complete audit of all resident's medication and submit findings to CCLD.

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: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CARMEL VILLAGE AT CLOVIS	FACILITY NUMBER: 107208995
	VISIT DATE: 08/13/2024

NARRATIVE

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Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/31/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020.

An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques Leffall	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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