107209059-11-1-2022-24-AS-MYAG-CKRRK4-20221101130456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107209059
Report Date: 11/01/2022
Date Signed: 11/01/2022 01:05:04 PM

Document Has Been Signed on 11/01/2022 01:05 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:	FAMILY STYLE SENIOR ASSISTED LIVING		FACILITY NUMBER:	107209059
ADMINISTRATOR:	MARTHA ZAPATA		FACILITY TYPE:	740
ADDRESS:	2202 STANFORD AVE		TELEPHONE:	(559) 396-1519
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	11/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:44 AM
MET WITH:	Administrator Martha Zapata		TIME COMPLETED:	01:10 PM

NARRATIVE

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On 11/01/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Administrator Martha Zapata. LPA toured facility with Administrator. All six residents and eight visitors were present during the inspection. Visitors were observed outside and in visitor area.

Upon entry facility staff and visitors was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. COVID-19 related signs and cough etiquette postings observed.

LPA checked residents’ locked medications. LPA observed 30 days PPE supplies. Food supply was checked and appeared to be an adequate supply. Four residents were observed in dining area. LPA and Administrator observed chemicals and knives stored unlocked under kitchen sink. All resident’s room toured and observed to be adequately furnished and lit. LPA observed three shared resident’s bedrooms to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. The exterior tour was conducted. Side gate was self-closing and free obstruction. Staff records were reviewed for good health and infection control training. All six resident records reviewed to have updated emergency contact information. LPA observed fire extinguisher served date: 12/20/21.

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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/07/22. The following updated forms were requested: Lic 308, Lic 500, and current liability insurance. LPA received a copy of Lic 610E. A copy of this report and appeal rights was provided to Administrator.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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 11/01/2022 01:05 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: FAMILY STYLE SENIOR ASSISTED LIVING	FACILITY NUMBER: 107209059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2022

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 Administrator observed at approximately 12:04PM, bottles of chemicals and knives unlocked with all four residents eating in the dining area. Chemicals and knives were stored unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2022
	Plan of Correction
1 2 3 4	Administrator immediately locked removed knives and chemicals into locked cabinet in the facility office. 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: Melinda Hoffmann	TELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

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