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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209000
Report Date: 05/10/2021
Date Signed: 05/10/2021 04:56:01 PM

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:LAURITE SENIOR CARE HOMEFACILITY NUMBER:
107209000
ADMINISTRATOR:DAVIS, MARITAFACILITY TYPE:
740
ADDRESS:5478 E LAURITE AVETELEPHONE:
(559) 246-1561
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: DATE:
05/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marita Davis, Administrator TIME COMPLETED:
12:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) S. Moua conducted a case management - deficiencies Televisit on this date with Administrator Marita Davis. Inspection was conducted in conjunction with the finding delivery of a complaint investigation. During the course of a complaint investigation, the following deficiencies were observed:

1. Resident was given a PRN medication, but administration of medication was not recorded on the MARs

2. Facility did not report resident's falls on 12/11/20, 12/19/20 and hospitalization

Deficiencies are observed on the attached 809-D. Exit interview was conducted. Appeal rights were provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021
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: LAURITE SENIOR CARE HOME
FACILITY NUMBER: 107209000
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2021
Section Cited

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87465(h)(6) Incidental Medical and Dental Care - The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained. This requirement was not met as evidenced by:
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Based on records reviewed and interviews conducted, medications given to R1 was not documented on the MARs, which poses an immediate risk to the residents.
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Type B
05/17/2021
Section Cited

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87211(a)(1)(B) Reporting Requirement Each licensee shall furnish to the licensing agency such reports as the Department may require...Any serious injury. This requirement was not met:
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Based on interviews conducted and records reviewed, R1's falls and hospitalization were not reported to the Department, which poses a potential health and safety risk to the residents.
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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: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2021
LIC809 (FAS) - (06/04)
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