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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209035
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:26:15 PM

Document Has Been Signed on 10/23/2024 12:26 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:TRUEWOOD BY MERRILL, CLOVISFACILITY NUMBER:
107209035
ADMINISTRATOR/
DIRECTOR:		MAZON, PAMELAFACILITY TYPE:
740
ADDRESS:675 W ALLUVIAL AVENUETELEPHONE:
(559) 325-8400
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 148CENSUS: 110DATE:
10/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:56 AM
MET WITH:Administrator: Pamela MazonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/23/24, Licensing Program Analyst (LPA) J. Leffall conducted a case management visit to follow up and confirm details of an incident report that was received by the Department. The incident occurred on 10/18/24, in which R1 was given medications after the expiration dates multiple times. LPA met with Administrator (A1) Pamela Mazon.

A1 stated that the facility completed medication training with staff and completion sheet submitted to CCLD.

A citation is issued on the attached 809-D regarding medications and R1 being given expired medications.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 10/23/2024 12:26 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/23/2024 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TRUEWOOD BY MERRILL, CLOVIS
FACILITY NUMBER: 107209035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
87465(a)(4)

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87465 (a) (4)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.
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A1 stated that the facility completed medication training with staff and completion sheet submitted to CCLD.
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Based on records reviewed and interviews conducted, R1 was not properly assisted with medications as needed and was given medications after the expiration date for 3 days, which poses an immediate Health & 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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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