107209035-7-7-2023-24-AS-MYAG-CTHTFW-20230707144212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209035
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:43:05 PM

Document Has Been Signed on 07/07/2023 02:43 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	TRUEWOOD BY MERRILL, CLOVIS		FACILITY NUMBER:	107209035
ADMINISTRATOR:	ROBERT HUNTLEY		FACILITY TYPE:	740
ADDRESS:	675 W ALLUVIAL AVENUE		TELEPHONE:	(559) 325-8400
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	148	CENSUS: 90	DATE:	07/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	General Manager Pamela Mazon		TIME COMPLETED:	02:30 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 07/07/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and were allowed entry into the facility. LPA met with General Manager (GM) Pamela Mazon. LPA conducted tour of facility with GM. Residents were observed seating in lobby and dining area. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 12/06/22. LPA interviewed residents and staffs. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer, walk-in refrigerator, and pantry. LPA observed a sufficient amount of non-perishable and perishable food supplies delivered by vendor. Refrigerator temperature was maintained at 38 degree F. and freezer was maintained at 0 degree F. Adequate PPE supplies was observed. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. LPA toured a sample of resident bedrooms in Assisted Living and Memory Care. LPA observed 10 of the 115 rooms in the facility. Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lightning. According to facility water temperature log, hot water temperature measured at between 118 degrees F. to 120 degrees F, within range. LPA observed securely fastened grab bars and non-skid mat in all tub/shower areas. At approximately 10:56 AM, LPA and GM observed multiple cleaning chemicals stored unlock under Memory Care kitchen sink. At approximately 11:14 AM, LPA and GM observed in the activity room on the 2^nd floor car cleaning chemicals stored unlock in the utility cabinet. Knives were observed in activity room kitchen drawers stored unlock. The outside was toured and observed to be free from debris. There was outdoor seating available for the residents.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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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Document Has Been Signed on 07/07/2023 02:43 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TRUEWOOD BY MERRILL, CLOVIS	FACILITY NUMBER: 107209035
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309(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, the Licensee did not comply with the section cited above when LPA and General Manager (GM) observed cleaning chemicals unlock in under Memory Care kitchen sink at approximately 10:56 AM. At approximately 11:14AM, LPA and GM observed care cleaning chemicals stored unlock in the utility cabinet in the activity room. Unlock knives were observed in the activity room kitchen drawers. Chemicals and knives were observed stored unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/08/2023
	Plan of Correction
1 2 3 4	General Manager immediately removed and locked the cleaning chemicals and knives. POC cleared during visit

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: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: TRUEWOOD BY MERRILL, CLOVIS	FACILITY NUMBER: 107209035
	VISIT DATE: 07/07/2023

NARRATIVE

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

An exit interview was conducted with the GM. The following documents are requested and submitted to Fresno CCL by: 07/13/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, Lic 9282, and current liability insurance. A copy of this report and appeal rights was given to the GM, whose signature on this form confirm receipt of these reports.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC809 (FAS) - (06/04)

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