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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209048
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:03:50 PM


Document Has Been Signed on 05/15/2024 04:03 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:RIVER BLUFFS MEMORY CARE COMMUNITYFACILITY NUMBER:
107209048
ADMINISTRATOR:HURLEY, DONNAFACILITY TYPE:
740
ADDRESS:5425 W. SPRUCE AVE.TELEPHONE:
(559) 840-9347
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:36CENSUS: 34DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Donna HurleyTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Donna Hurley and Wellness Director (WD) Alexis Martin. AD re-certification was confirmed to be in process during the visit.

During this visit, LPA toured the facility inside & out Resident rooms are found to be in good repair and contained required furnishings and lighting. The resident bathrooms was clean and in good repair with faucets delivering hot water within required limits, grab bars and non-skid shower floors observed. LPA observed required hygiene items, towels, extra bedding, and linens were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are locked and stored separate from food. Medications are locked and centrally stored in a medication cart. The First aid kit contained required items. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were serviced by Valley Fire Co. on 4/5/2024. LPA conducted resident and staff file reviews. A medication audit was also conducted Emergency Disaster Plan and Infection Control Plans were reviewed during this visit and found to be updated.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D in the area of: Hospice Care Waiver and Incidental Medical and Dental Care.



An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.

LPA requested the following updated forms faxed to CCLD by 5/22/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Surety Bond (Lic402), Emergency Disaster Plan (LIC610E), Client Roster (LIC 9020), Proof of current Liability Coverage.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 04:03 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: RIVER BLUFFS MEMORY CARE COMMUNITY
FACILITY NUMBER: 107209048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)(1)

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department…. The request shall include, but not be limited to the following: (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Record review and interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility has a Hospice Waiver for 8. There are currently 9 residents admitted to and receiving Hospice care.
POC Due Date: 05/22/2024
Plan of Correction
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AD has agreed to submit a request to increase hospice capasity from 8 to 9 residents. The written request will be submitted via fax to CCLD by POC date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 3 medication count audits medication start dates were not accurately recorded which poses/posed a potential health, safety or personal rights risk to persons in care. R1 Pantoprazole start date 4/17/24 and R2 Aspirin start date is not recorded on the centrally stored log.
POC Due Date: 05/22/2024
Plan of Correction
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AD has agreed to provide an in person in-service to review facility medication documentation requirements and procedure with all Med Techs. Sign in sheet with names and signature will be provided along with training materials. This will be submitted to CCLD by POC date.
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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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