107209036-5-1-2023-24-AS-KBRN-CREU5X-20230501151727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209036
Report Date: 05/01/2023
Date Signed: 05/01/2023 03:17:36 PM

Document Has Been Signed on 05/01/2023 03:17 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:	OAKMONT OF NORTH FRESNO		FACILITY NUMBER:	107209036
ADMINISTRATOR:	GUSTIN, PATRICIA		FACILITY TYPE:	740
ADDRESS:	5605 N GATES AVE		TELEPHONE:	(559) 277-5959
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	122	CENSUS: 80	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Heidi Setty		TIME COMPLETED:	03:45 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	Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Heidi Setty. During this visit, LPA toured the facility inside & out. Resident bedrooms contained required furnishings and lighting. LPA observed hand washing signs and required items in bathrooms. Resident hygiene supplies were properly stored. Hot water temperature measured within required range. The kitchen observed clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Medications are centrally stored and locked. First aid kit contained required items. Facility has designated visitation areas available inside and out. Outside of the facility toured. LPA observed delayed egress doors and gates in Memory Care. Doors and passageways are unobstructed throughout the facility and outside. Fire Extinguishers dated 12/28/22. Smoke and Carbon Monoxide detectors present and in working order. LPA conducted resident and staff file reviews and interviews. Administrator Certification expiration 7/29/24. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Heidi Setty, whose signature on this form confirms receipt of these documents. LPA requested the following updated forms faxed to CCLD by 5/22/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Emergency Disaster Plan (Lic610E), Personnel Report (LIC 500), Client Roster (LIC 9020), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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 05/01/2023 03:17 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: OAKMONT OF NORTH FRESNO	FACILITY NUMBER: 107209036
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of 2 resident Centrally Stored Medication Log and Medication Administration Record (MAR) the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Additionally, LPA Kaur conducted a pill count which identified that there were extra pills that had not been given with no documentation as to why. MAR indicated that all meds were given on time.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to submit a written statement which will include schedule of a med cart audit of 10%. Additionally, the statement will include the in-service plan. Licensee has agreed that the audit, in-service and proof of in-service will be complete and submitted by 5PM 5/22/23.

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: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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